,i #aafth ,,congress #ast ,session ,h4 ,r4 #bdeb ,,in ,,the ,,house ,,of ,,representatives ,may #a1 #bjai,ms4 ,de,lauro 7for herself1 ,ms4 ,schakowsky1 ,mr4 ,kennedy1 ,mr4 ,clay1 ,ms4 ,norton1 ,mr4 ,grijalva1 ,mr4 ,carbajal1 ,mrs4 ,trahan1 ,mr4 ,ryan1 ,ms4 ,jackson ,lee1 ,mr4 ,thompson of ,mississippi1 ,ms4 ,roybal-,allard1 ,ms4 ,mc,collum1 ,ms4 ,moore1 ,mr4 ,rush1 and ,mr4 ,higgins of ,new ,york7 introduced the following bill2 which was referred to the ,committee on ,ways and ,means1 and in addition to the ,committees on ,energy and ,commerce1 ,education and ,labor1 the ,judiciary1 ,natural ,resources1 and ,house ,administration1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend the ,social ,security ,act to establish a ,medicare for ,america health program to provide for comprehensive health coverage for all ,americans4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,medicare for ,america ,act of #bjai4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,title ,i--,transitioning to and ,establishing ,medicare for ,america ,subtitle ,a--,transitional public health option ,sec4 #aja4 ,establishment4 ,sec4 #ajb4 ,eligibility4 ,sec4 #ajc4 ,benefits4 ,sec4 #ajd4 ,premiums4 ,sec4 #aje4 ,providers and reimbursement rates4 ,sec4 #ajf4 ,account2 funding4 ,subtitle ,b--,medicare for ,america ,sec4 #aaa4 ,establishment and administration of ,medicare for ,america4 ,sec4 #aab4 ,modifications to and coordination with existing ,federal health programs4 ,subtitle ,c--,targeted ,reforms ,sec4 #aba4 ,no surprise billing4 ,sec4 #abb4 ,limitation on removal of ,medicare ,advantage providers by ,,ma organizations4 ,sec4 #abc4 ,network adequacy4 ,sec4 #abd4 ,eliminating the #bd-month waiting period for ,medicare coverage for individuals with disabilities4 ,sec4 #abe4 ,eliminating the waiting period for individuals on ,state ,medicaid waiting lists4 ,sec4 #abf4 ,employer health plan options4 ,sec4 #abg4 ,prohibition on step therapy and prior authorization under group health plans4 ,sec4 #abh4 ,medicare outpatient observation services4 ,sec4 #abi4 ,abortion coverage4 ,sec4 #acj4 ,applicability of mental health parity4 ,sec4 #aca4 ,student loan forgiveness for health care providers participating in ,medicare for ,america4 ,sec4 #acb4 ,clarification of the definition of pediatric medical necessity in qualifying group coverage4 ,sec4 #acc4 ,safe staffing requirements4 ,sec4 #acd4 ,enhancements for reduced cost-sharing4 ,sec4 #ace4 ,repeal of bonus payments for ,medicare ,advantage plans4 ,title ,,ii--,,tax ,,provisions ,sec4 #bja4 ,sunset of ,public ,law #aae-ig4 ,sec4 #bjb4 ,surtax4 ,sec4 #bjc4 ,basis of property acquired from a decedent4 ,sec4 #bjd4 ,medicare payroll tax4 ,sec4 #bje4 ,net investment income tax4 ,sec4 #bjf4 ,termination of deduction for contributions to health savings accounts4 ,sec4 #bjg4 ,increase in excise tax on small cigars and cigarettes and other tobacco products4 ,sec4 #bjh4 ,excise tax on alcohol4 ,sec4 #bji4 ,tax on sugared drinks4 ,sec4 #baj4 ,repeal of excise tax on high-cost employer-sponsored health coverage4 ,title ,,iii--,,drug-,,related ,,provisions ,sec4 #cja4 ,establishment of the ,prescription ,drug and ,medical ,device ,review ,board4 ,sec4 #cjb4 ,membership2 staff4 ,sec4 #cjc4 ,prohibition against excessive price4 ,sec4 #cjd4 ,enforcement provisions4 ,sec4 #cje4 ,authority4 ,sec4 #cjf4 ,regulations4 ,sec4 #cjg4 ,report to ,federal agencies4 ,sec4 #cjh4 ,definitions4 ,sec4 #cji4 ,moratorium on direct-to-consumer drug advertising4 ,sec4 #caj4 ,reporting on justification for drug price increases4 ,title ,,iv--,outcomes and ,reporting ,sec4 #dja4 ,sense of ,congress4 ,sec4 #djb4 ,evaluation of bill's outcome4 ,i ,transitioning to and ,establishing ,medicare for ,america ,a ,transitional public health option #aja4 ,establishment ,the ,secretary of ,health and ,human ,services 7in this subtitle referred to as the ,secretary7 shall establish a public health plan option that is offered in the individual market through the ,federal and ,state ,exchanges under title ,i of the ,patient ,protection and ,affordable ,care ,act to eligible individuals for plan years #bjba and #bjbb in accordance with this subtitle4 #ajb4 ,eligibility ,subject to subsection 7b71 an individual is eligible to enroll in such public health plan option if the individual is otherwise eligible to purchase individual health insurance coverage through an ,exchange and the individual resides in a rating area in which the ,secretary makes the public health plan option available4 #ajc4 ,benefits 7a7 ,in general ,the public health plan option shall be a qualified health plan within the meaning of section #acja7;a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjba7;a77 that-- 7#a7 meets all requirements applicable to qualified health plans under subtitle ,d of title ,i of the ,patient ,protection and ,affordable ,care ,act 7other than the requirement under section #acja7;a77#a77;,c77ii7 of such ,act 7#db ,u4,s4,c4 #ahjba7;a77#a77;,c77ii777 and title ,,xxvii of the ,public ,health ,service ,act2 7#b7 provides coverage of the essential health benefits described in section #acjb7;b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;b772 7#c7 provides silver and gold-level coverage described in section #acjb7;d77#a77;,c7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;d77#a77;,c772 and 7#d7 provides coverage of comprehensive reproductive health services1 including abortion4 7b7 ,preemption ,notwithstanding section #acjc7;a77#a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbc7;a77#a77-- 7#a7 a ,state may not prohibit the public health plan option from offering the coverage described in subsection 7a77#d72 and 7#b7 no ,state law that would prohibit such a plan from offering such coverage shall apply to such plan4 #ajd4 ,premiums 7a7 ,in general ,the ,secretary shall establish premium rates for the public health plan option that-- 7#a7 are adjusted based on the applicable rating area2 7#b7 are at a level sufficient to fully finance-- 7,a7 the costs of health benefits provided by such plans2 and 7,b7 administrative costs related to operating the plans2 7#c7 comply with the requirements under section #bgja of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg72 and 7#d7 ensure that no individual or household will pay more than #h percent of adjusted gross monthly income toward the monthly premium4 7b7 ,federal subsidies ,federal subsidies shall be provided to ensure that the premium shall be-- 7#a7 zero in the case of an individual whose annual household income is below #bjj percent of the poverty line2 7#b7 determined by a linear sliding scale1 in the case of an individual whose household income is at least #bjj percent of the poverty line1 but not more than #fjj percent of the poverty line2 and 7#c7 no individual or household above #fjj percent of poverty level will pay more than #h percent of adjusted gross monthly income toward such monthly premium4 #aje4 ,providers and reimbursement rates 7a7 ,in general ,the ,secretary shall establish a rate schedule for reimbursing types of health care providers furnishing items and services under the public health insurance plan option at rates based on rates applied for such items and services under title ,,xviii of the ,social ,security ,act1 as of the date of the enactment of this ,act1 that are necessary to maintain network adequacy4 ,the ,secretary shall establish a rate schedule for items and services not currently covered under title ,,xviii of the ,social ,security ,act1 such as dental1 vision1 and hearing benefits1 well child visits1 and reproductive health services1 at a level to ensure adequate access to providers4 7b7 ,participating providers 7#a7 ,in general ,a health care provider that is a participating provider of services or supplier under the ,medicare program under title ,,xviii of the ,social ,security ,act or under the ,medicaid program under title ,,xix of such ,act on the date of enactment of this title shall be a participating provider for the public health insurance plan option4 7#b7 ,additional providers ,the ,secretary shall establish a process to allow health care providers not described in paragraph 7#a7 to become participating providers for the public health insurance plan option4 7#c7 ,clarification ,notwithstanding any other provision of law1 health care providers may not be prohibited from participating in the public health insurance option for reasons other than their ability to provide covered services4 ,health care providers and institutions are prohibited from denying covered individuals access to any covered benefits and services because of their religious objections4 7c7 ,prescription drugs ,the ,secretary shall apply the provisions of section #ahfj;,d-#aa7;i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aaa7;i77 to prescription drugs under the public health plan option in the same manner as such provisions apply with respect to applicable covered part ,d drugs under such section4 #ajf4 ,account2 funding 7a7 ,establishment ,there is established in the ,treasury of the ,united ,states an account for the receipts and disbursements attributable to the operation of the public health plan option4 7b7 ,appropriation ,there is appropriated to the account established under subsection 7a71 out of any funds in the ,treasury not otherwise obligated1 such sums as may be necessary to be used by the ,secretary for purposes of carrying out this part4 7c7 ,prohibition of ,state imposition of taxes ,section #ahed7;g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bd7;g77 shall apply to receipts and disbursements described in subsection 7a7 in the same manner as such section applies to payments or premiums described in such section4 7d7 ,clarification ,any provision of law restricting the use of ,federal funds with respect to any reproductive health service shall not apply to funds appropriated under subsection 7b7 or with respect to the account under subsection 7a74 ,b ,medicare for ,america #aaa4 ,establishment and administration of ,medicare for ,america ,the ,social ,security ,act is amended by adding at the end the following new title3 ,,xxii ,,medicare ,,for ,,america ,a ,,comprehensive ,,health ,,coverage #bbja4 ,establishment ,the ,secretary shall establish a public health insurance program1 to be known as ,medicare for ,america1 which shall for calendar year #bjbc and each subsequent calendar year provide comprehensive health benefits in accordance with this part to individuals enrolled for coverage under this title4 #bbjb4 ,eligibility2 automatic enrollment 7a7 ,eligible individuals ,for purposes of this title1 every individual who is-- 7#a7 a resident of the ,united ,states or a territory of the ,united ,states2 7#b7 an individual who is lawfully present1 as defined in section #aeb4b of title #de of the ,code of ,federal ,regulations2 or 7#c7 an individual who would be eligible for coverage under a ,state ,medicaid plan pursuant to section #aijc7v7 7as such section was in effect as of the date of the enactment of this title71 is entitled to benefits for health care services under this title4 ,the ,secretary shall promulgate a rule that provides criteria for applying this subsection1 including determining residency for eligibility purposes under this title4 ,nothing in this title shall preclude a ,state from using ,state funds to provide for an individual's health coverage who is not eligible under this subsection4 7b7 ,enrollments ,subject to subsection 7c73 7#a7 ,in general ,beginning in #bjbc1 the ,secretary shall provide a mechanism for the enrollment of individuals entitled to benefits under this title and1 in conjunction with such enrollment1 the issuance of a ,medicare for ,america card which may be used for purposes of identification and processing of claims for benefits under this title4 ,the card shall not use the individual's social security number as an identifier4 ,as a condition of participation in the program1 participating providers shall facilitate enrollment as specified by the ,secretary4 ,the ,state entities responsible for enrolling individuals in the ,medicaid program under title ,,xix and the ,children's ,health ,insurance ,program under title ,,xxi shall serve as the enrolling entity for ,medicare for ,america within each ,state4 7#b7 ,automatic enrollments ,the mechanism provided under paragraph 7#a7 shall1 subject to paragraph 7#d71 provide1 for plan years1 for the following automatic enrollments under ,medicare for ,america3 7,a7 ,enrollment at birth ,for plan years 7beginning with plan year #bjbc71 a process1 established by the ,secretary in consultation with the ,commissioner of ,social ,security1 for the automatic enrollment of eligible individuals born during such plan year4 7,b7 ,current medicare beneficiaries 7i7 ,current medicare beneficiaries ,for plan years 7beginning with plan year #bjbc71 a process established by the ,secretary for the automatic enrollment of all individuals who are enrolled for benefits under part ,a or ,b of title ,,xviii 7other than individuals who are enrolled for such benefits and receiving benefits under title ,,xix74 7ii7 ,continuing population ,for plan years 7beginning with plan year #bjbc71 a process established by the ,secretary for the automatic enrollment of eligible individuals who attain the age of #fe during such plan year4 7iii7 ,duals ,for plan years 7beginning with plan year #bjbe71 a process established by the ,secretary for the automatic enrollment of eligible individuals who are enrolled for benefits under part ,a or ,b of title ,,xviii and receiving benefits under title ,,xix4 7,c7 ,other individuals without qualified health coverage ,for plan years 7beginning with plan year #bjbc71 a process established by the ,secretary for the automatic enrollment of eligible individuals who are not enrolled in other qualified health coverage 7as defined in paragraph 7#d77;,b77 for such plan year4 7#c7 ,other enrollments ,the mechanism provided under paragraph 7#a7 shall provide for the following3 7,a7 ,in general ,enrollment periods and processes for each plan year 7beginning with plan year #bjbc7 for enrollment under ,medicare for ,america of any eligible individual not otherwise described in paragraph 7#b74 7,b7 ,small employers 7i7 ,in general ,for plan years 7beginning with plan year #bjbc71 a process and methodology under which a small employer1 as defined in section #abf7;d77#c7 of the ,medicare for ,america ,act1 may provide for the enrollment of the employees of such employer under ,medicare for ,america4 ,for purposes of this subparagraph1 the term small employer means any employer for any calendar year if the annual payroll of such employer for the preceding calendar year does not exceed #b1jjj1jjj or has fewer than #ajj employees4 7ii7 ,requirement ,small employers shall either provide coverage as defined within the meaning of section #bgia7;d77#h7 of the ,public ,health ,service ,act or facilitate the enrollment of their employees into ,medicare for ,america4 ,small employers facilitating enrollment into ,medicare for ,america will not be subject to a mandatory employer contribution4 7iii7 ,authority ,the ,secretary may set standards for determining whether employers are undertaking any actions to affect the risk pool within ,medicare for ,america by inducing individuals to decline coverage under a qualifying employer-sponsored plan and instead to enroll in ,medicare for ,america4 ,an employer violating such standards shall be treated as not meeting the requirements of qualified health coverage4 7,c7 ,large employers ,for plan years 7beginning with plan year #bjbg71 the ,secretary shall provide for a process and methodology under which a large employer may provide for the enrollment of the employees of such employer under ,medicare for ,america4 ,for purposes of the preceding sentence1 the term large employer means an employer with at least #ajj employees or whose annual payroll exceeds #b1jjj1jjj4 7,d7 ,members of ,congress and ,their ,staff ,beginning for plan year #bjbc1 ,members of ,congress and their staff1 subject to paragraph 7#d71 shall be enrolled in ,medicare for ,america4 7#d7 ,opt out for individuals enrolled under qualified health coverage 7,a7 ,in general ,the mechanism provided under paragraph 7#a7 shall provide1 with respect to a plan year1 for a process that enables individuals who are enrolled in qualified health coverage for such plan year to opt out of coverage under ,medicare for ,america for such year4 7,b7 ,qualified health coverage defined ,for purposes of this section1 the term qualified health coverage means coverage under any of the following3 7i7 ,for plan years #bjbc and #bjbd3 7,i7 ,qualified employer coverage1 as defined in section #abf of the ,medicare for ,america ,act4 7,,ii7 ,medical coverage under chapter #ee of title #aj1 ,united ,states ,code1 including coverage under the ,,tricare program4 7,,iii7 ,a health care program under chapter #ag or #ah of title #ch1 ,united ,states ,code1 as determined by the ,secretary of ,veterans ,affairs1 in coordination with the ,secretary of ,health and ,human ,services and the ,secretary4 7,,iv7 ,the health benefit program under chapter #hi of title #e1 ,united ,states ,code4 7,v7 ,medical benefits and services provided by or through the ,indian ,health ,service4 7,,vi7 ,the ,medicaid program under title ,,xix of the ,social ,security ,act4 7,,vii7 ,the ,,chip program under title ,,xxi of the ,social ,security ,act4 7ii7 ,for plan years #bjbe and #bjbf3 7,i7 ,coverage described in subclause 7,i71 7,,ii71 7,,iii71 7,,iv71 or 7,v7 of clause 7i74 7,,ii7 ,coverage described in subclause 7,,vi7 of clause 7i71 but only with respect to coverage that is not for individuals described in subclause 7,,viii7 of section #aijb7;a77#aj77;,a77i7 or who are also enrolled for benefits under title ,,xviii4 7iii7 ,for each subsequent plan year1 coverage described in subclause 7,i71 7,,ii71 7,,iii71 7,,iv71 or 7,v7 of clause 7i74 7c7 ,waiver ,the ,secretary shall establish a process under which the ,secretary may grant waivers to ,states for additional time before populations described in a previous subsection of this section of such ,state are automatically enrolled under ,medicare for ,america so long as the ,state can demonstrate substantial progress has been made in transitioning these populations4 #bbjc4 ,benefits 7a7 ,in general ,medicare for ,america shall1 in accordance with this section1 provide coverage for all the benefits1 as determined to be medically necessary1 as covered and defined under parts ,a and ,b of title ,,xviii and title ,,xix as of the date of the enactment of this title1 including the following3 7#a7 ,ambulatory patient services4 7#b7 ,emergency care and urgent care services4 7#c7 ,hospitalization4 7#d7 ,maternity and newborn care4 7#e7 ,behavioral health services1 including mental health1 substance use disorder services1 and intensive home and community based services4 7#f7 ,prescription drugs approved by the ,food and ,drug ,administration4 7#g7 ,rehabilitative and habilitative services and devices1 including the following3 7,a7 ,physical therapy4 7,b7 ,speech therapy4 7,c7 ,occupational therapy4 7#h7 ,laboratory services4 7#i7 ,preventive and wellness services and chronic disease management4 7#aj7 ,pediatric services1 all services that would otherwise be coverable under early and periodic screening1 diagnostic1 and treatment under the ,medicaid program under title ,,xix and services otherwise included under the maternal1 infant1 and early childhood home visiting program under section #eaa1 as of the date of the enactment of this title4 7#aa7 ,dental care1 at a minimum the services necessary to prevent disease and promote oral health1 restore oral structures to health and function1 and treat emergency conditions1 nightguards1 mouthguards1 and dentures4 7#ab7 ,hearing health services including aids and exams4 7#ac7 ,vision services4 7#ad7 ,home and community based long-term services and supports4 7#ae7 ,chiropractic services4 7#af7 ,durable medical equipment 7as defined for purposes of title ,,xix71 including the following3 7,a7 ,wheelchairs and accessories4 7,b7 ,walking aides such as walkers1 canes1 and crutches4 7,c7 ,bathroom equipment such as commodes and safety equipment4 7,d7 ,inhalation therapy equipment such as nebulizers4 7,e7 ,hospital beds and accessories4 7,f7 ,other devices such as ,continuous ,positive ,airway ,pressure 7,,cpap7 machines1 apnea monitors1 and ventilators4 7,g7 ,insulin pumps and glucometers4 7,h7 ,breast pumps4 7,i7 ,lymphedema compression treatment items4 7,j7 ,wigs for medical conditions4 7,k7 ,augmentative and alternative communication devices1 including dual-use devices4 7,l7 ,oxygen4 7,m7 ,orthotic and prosthetic devices4 7,n7 ,disposable medical supplies4 7#ag7 ,family planning1 including the following3 7,a7 ,reproductive health exams4 7,b7 ,patient counseling and education related to family planning4 7,c7 ,abortion4 7,d7 ,screening1 testing1 treatment1 and pre- and post-test counseling for sexually transmitted diseases and ,,hiv4 7,e7 ,contraceptives including pill1 patch1 medication1 condom1 implant1 or other devices used to prevent pregnancy4 7,f7 ,voluntary sterilization for beneficiaries over the age of #ba4 7,g7 ,infertility treatment4 7#ah7 ,gender-confirming medical procedures and treatment4 7#ai7 ,screening1 testing1 treatment1 and pre- and post-test counseling for sexually transmitted diseases and ,,hiv4 7#bj7 ,dietary and nutrition counseling4 7#ba7 ,medically necessary food and vitamins for digestive and inherited metabolic disorders4 7#bb7 ,nursing facilities4 7#bc7 ,acupuncture4 7#bd7 ,digital health therapeutics1 as approved by the ,center for ,healthcare and the ,center for ,medicare and ,medicaid ,innovation4 7#be7 ,telehealth4 7#bf7 ,non-emergency medical transportation4 7#bg7 ,care coordination1 including services defined in section #ddj4afi of title #db1 ,code of ,federal ,regulations4 7#bh7 ,palliative care4 7#bi7 ,any additional benefit or service not included in this section that is coverable by any ,state plan 7or waiver of such ,state plan7 under title ,,xix on the date of the enactment of this title4 7b7 ,updates ,benefits coverable under ,medicare for ,america shall be updated in accordance with the ,national ,coverage ,determination process that had1 as of the date before the date of the enactment of this title1 applied with respect to benefits covered under title ,,xviii4 7c7 ,implementing policies ,the ,secretary shall establish payment models1 quality measures1 and other implementing policies that provide further access to the coverage under this title4 ,for purposes of the previous sentence1 the ,secretary shall consult with stakeholders1 including those covering pediatrics1 disabilities1 and seniors4 7d7 ,prohibition against duplicating coverage 7#a7 ,in general ,it is unlawful for a private health insurer 7other than an insurer with respect to a ,medicare ,advantage for ,america plan under part ,c of this title or qualified employer-based coverage7 to sell health insurance coverage that duplicates the benefits provided under ,medicare for ,america under this part4 7#b7 ,construction ,nothing in paragraph 7#a7 shall be construed as prohibiting the sale of health insurance coverage for any additional benefits not covered by this part1 insofar as the coverage satisfies the conditions of paragraphs 7#c7 and 7#d74 ,nothing shall preclude employers meeting the requirements under section #abf of the ,medicare for ,america ,act from providing supplemental coverage under this section to their employees4 7#c7 ,application of protections ,for purposes of paragraph 7#b71 health insurance coverage for any additional benefits must satisfy the following conditions3 7,a7 ,the provisions of section #bgah of the ,public ,health ,service ,act1 relating to a medical loss ratio4 7,b7 ,the provisions of section #bgjb of the ,public ,health ,service ,act1 relating to guaranteed issue4 7,c7 ,the provisions of section #bgja of the ,public ,health ,service ,act1 relating to community rating4 7,d7 ,the provisions of section #bgjd of the ,public ,health ,service ,act1 relating to the ban on pre-existing conditions exclusions4 7#d7 ,no fees to brokers ,for purposes of paragraph 7#b71 the condition described in this paragraph is that health insurance coverage described in such paragraph does not pay fees to insurance brokers4 7e7 ,states may provide additional benefits ,individual ,states may provide additional benefits for the residents of such ,states at the expense of the ,state4 7f7 ,prohibition against step therapy and prior authorization ,items and services covered under ,medicare for ,america shall be covered without any need for any prior authorization determination and without any limitation applied through the use of step therapy protocols4 #bbjd4 ,premiums 7a7 ,in general 7#a7 ,in general ,subject to paragraph 7#b71 each individual enrolled for benefits under this title for a year shall pay monthly community-rated premiums for such year in an amount determined by the ,secretary in accordance with subsection 7b74 7#b7 ,grandfathered ,medicare beneficiaries ,in the case of an individual enrolled under part ,b of title ,,xviii as of the date of the enactment of this part1 the premium applied under this section for such individual for benefits under this title shall be the lesser of-- 7,a7 the premium otherwise applicable to such individual under such title ,,xviii if this title had not been enacted2 or 7,b7 the premium that would be applied to such individual under this title without the application of this paragraph4 7b7 ,premium contribution based on income ,the amount of a monthly premium1 with respect to a plan year 7beginning with #bjbc71 under this section shall be established by the ,secretary in accordance with the following3 7#a7 ,such premium shall be determined such that the collective premiums for the plan year are with respect to the costs of health benefits provided under this title for such year and related administrative costs4 7#b7 ,premiums shall vary by family composition only4 7#c7 ,federal subsidies shall be provided to ensure that the premium shall be-- 7,a7 zero in the case of an individual whose annual household income is below #bjj percent of the poverty line2 7,b7 determined by a linear sliding scale1 in the case of an individual whose household income is at least #bjj percent of the poverty line1 but not more than #fjj percent of the poverty line2 and 7,c7 no individual or household will pay more than #h percent of adjusted gross monthly income toward such premium4 7#d7 ,for an individual whose employer will be making a firm-wide contribution under this title in lieu of offering employer-sponsored insurance 7as specified in section #abf7;b77#a77;,b7 of the ,medicare for ,america ,act71 such individual shall pay a premium in accordance with this subsection4 7#e7 ,for an individual who has opted out of their employer-sponsored insurance in order to enroll in ,medicare for ,america as specified in section #abf7;c7 of such ,act1 the individual shall pay the lesser of-- 7,a7 the premium described in this subsection2 or 7,b7 the amount owed after the amount of employer contribution 7as specified in section #abf7;b77#a77;,b7 of the ,medicare for ,america ,act7 is subtracted from the premium established by the ,secretary of ,health and ,human ,services as described in paragraph 7#a71 whichever is less4 7c7 ,deposits ,amounts paid under this section for coverage under this title shall be deposited in the ,treasury to the credit of the ,trust ,fund established under section #bbjf4 7d7 ,appeals for certain medicare grandfathered population ,in calculating premiums for purposes of subsection 7a77#b73 7#a7 ,any individual that was subject to a late enrollment penalty under part ,b of title ,,xviii shall have the right to appeal the assessment of the penalty for good faith enrollment mistakes4 7#b7 ,the ,secretary1 in consultation with the ,commissioner of ,social ,security1 shall develop and publish a formal application for requesting an action of the ,secretary under paragraph 7#a7 to correct or eliminate the effects of an error1 misrepresentation1 or inaction described in such paragraph and determine and publish specific timelines for timely resolution of such a request4 7#c7 ,the ,secretary shall also require that all such determinations with respect to such requests shall be reached within #ae business days of the submission of such application4 ,all determinations shall be in writing through a standard decision notice which shall include an explanation of the reasons for the determination4 7#d7 ,the ,commissioner of ,social ,security shall enter into contracts with independent review organizations in accordance with this subsection for the purpose of reviewing and determining individual appeals of determinations under paragraph 7#c7 with respect to an application relating to enrollment under part ,a or part ,b4 7#e7 ,an individual who receives an adverse determination under paragraph 7#c7 may appeal to an independent review organization designated by the ,commission4 ,any such appeal must be sent to the independent review organization within #ij days of the date the individual received the determination to be eligible for review4 ,the independent review organization shall review and reach a determination of the review in writing within #de days of the receipt of any such appeal4 7#f7 ,the ,secretary of the ,treasury may not enter into a contract under paragraph 7#d7 with an independent review organization-- 7,a7 unless the organization has staff that has the appropriate knowledge of1 and experience with1 the eligibility and coordination of benefits rules and regulations under this title2 and 7,b7 to the extent the organization is a fiscal intermediary under section #ahaf1 a carrier under section #ahdb1 or a ,medicare administrative contractor under section #ahgd;,a4 7#g7 ,the ,secretary shall provide for access by independent review organizations conducting appeal determinations under this subsection1 to the database of the ,coordination of ,benefits ,contractor of the ,centers for ,medicare ,medicaid ,services as necessary in order to conduct the duties of such organizations to determine appeals pursuant to this subsection4 #bbje4 ,payment of benefits2 cost-sharing2 out-of-pocket limits 7a7 ,payment of benefits2 cost-,sharing ,there shall be paid1 in the case of each individual who is enrolled under ,medicare for ,america and incurs expenses for items and services with respect to which benefits are payable under this part1 subject to subsection 7c71 #hj percent of the reimbursement rates established pursuant to section #bbjf for such items and services1 except that for the following services1 the amounts paid under this section shall be equal to #ajj percent of the reimbursement rates established pursuant to section #bbjf for such items and services3 7#a7 ,,usptf recommended preventive and chronic disease services4 7#b7 ,long-term services and supports4 7#c7 ,generic drugs1 and prescription drugs if medically necessary4 7#d7 ,all services for individuals who are medically frail or otherwise have special medical needs1 7including children with serious emotional disturbance and adults with serious mental illness71 individuals with chronic substance use disorders1 or individuals with serious and complex medical conditions 7such as epilepsy and ,,hiv71 individuals with a physical1 intellectual or developmental disability that significantly impairs their ability to perform one or more activities of daily living4 7#e7 ,pregnancy related services4 7#f7 ,emergency services4 7#g7 ,services for children under age #ba4 ,the ,secretary shall establish a default monthly payment plan under the ,medicare for ,america benefits package to ensure the payment owed by the individual enrolled under ,medicare for ,america is spread-out evenly throughout the year4 7b7 ,deductible ,there shall be no deductible under ,medicare for ,america4 7c7 ,maximum out-of-,pocket limit 7#a7 ,in general ,the coverage under ,medicare shall provide benefits1 after the eligible individual has incurred out-of-pocket expenses for items and services with respect to which benefits are payable under this part in a year equal to the annual out-of-pocket threshold specified in paragraph 7#b71 with cost-sharing that is equal to #j4 7#b7 ,annual out-of-pocket threshold 7,a7 ,in general ,for purposes of paragraph 7#a71 subject to subparagraphs 7,b7 and 7,c71 the annual out-of-pocket threshold specified in this paragraph is a threshold that shall be determined on a linear sliding scale for household income that is at least #bjj percent of the poverty line1 but not more than #fjj percent of the poverty line1 and that shall not exceed-- 7i7 with respect to an individual1 #c1ejj2 or 7ii7 with respect to a household1 #e1jjj4 ,individuals or households with income above #fjj percent of the ,federal poverty line shall have their annual out-of-pocket threshold capped at #c1ejj and #e1jjj respectively4 7,b7 ,indexing ,in the case of plan years beginning after #bjba1 the threshold described in subparagraph 7,a7 7as in effect for the preceding plan year after application of this subparagraph7 shall be increased by the percentage increase over the previous year in the medical care expenditure category of the ,consumer ,price ,index for ,all ,urban ,consumers 7,united ,states city average71 published by the ,bureau of ,labor ,statistics4 7,c7 ,exception ,for purposes of paragraph 7#a71 the annual out-of-pocket threshold for individuals and households with annual income below #bjj percent of the ,federal poverty line is #j4 7d7 ,no lifetime or annual limits ,there shall be no lifetime or annual limits for any services or benefits coverable under ,medicare for ,america4 7e7 ,no balance billing ,no provider may impose a charge to an enrolled individual for coverable services for which benefits are provided under this part in an amount higher than the reimbursement rate for such services under section #bbjf and may not impose a charge to such individual for such service other than with respect to the other cost-sharing described in this section4 7f7 ,no private contracting ,a health care provider or health care institution are prohibited from entering into a private contract with an individual enrolled under ,medicare for ,america for any item or service coverable under ,medicare for ,america4 7g7 ,limitations on the ,use of ,flexible ,savings ,accounts ,flexible ,savings ,accounts shall only be used for benefits and services not covered by ,medicare for ,america4 #bbjf4 ,providers network and reimbursement rates 7a7 ,in general ,the ,secretary shall establish a rate schedule for reimbursing types of health care providers furnishing items and services under ,medicare for ,america at rates that are consistent with subsection 7b7 and are necessary to maintain network adequacy4 7b7 ,rates 7#a7 ,in general ,except as provided in paragraphs 7#b7 and 7#c71 the ,secretary shall establish rates for benefits and services to be provided to health care providers and suppliers furnishing under ,medicare for ,america based on rates that would be applied 7including as computed1 updated1 and adjusted7 under title ,,xviii or title ,,xix1 whichever is higher1 for such type of health care providers and suppliers and item and service if such title remained in effect and1 in the case of a type of provider and supplier or item or service coverable under ,medicare for ,america but not otherwise coverable under title ,,xviii or title ,,xix1 shall provide for rates that ensure adequate access to care4 7#b7 ,exceptions ,for purposes of this section1 in applying paragraph 7#a7 the ,secretary shall ensure that rates to hospitals for inpatient services or outpatient services furnished under ,medicare for ,america are at least #aaj percent of such rates on average or in the aggregate for furnishing such inpatient or outpatient services otherwise applied under title ,,xviii or title ,,xix1 whichever is higher1 except that for hospitals serving underserved areas as specified by the ,secretary1 such rates are increased as necessary to ensure adequate access to care4 7#c7 ,application ,in applying rates under title ,,xviii and title ,,xix1 as applicable1 for purposes of this part1 the following shall apply3 7,a7 ,the ,secretary shall provide for site-neutral payments for items and services furnished in an outpatient hospital and physician office1 the rate of payment for such service shall be the same4 7,b7 ,the ,secretary shall provide for a mechanism to provide payments for direct and indirect costs of graduate medical education programs without any cap on the number of residency positions for which payment may be made1 including payments to hospitals for such programs and to eligible facilities for programs for population health-based residencies and for nurse practitioner post-licensure clinical training1 residency1 and fellowship programs4 7,c7 ,the ,secretary shall increase the average relative value of primary care and other mental and behavioral health and cognitive services by not less than #cj percent in order to ensure adequate access to inpatient and outpatient care4 7,d7 ,as a condition of participation in the program1 participating providers shall accept ,medicare for ,america rates paid by employer-sponsored insurance plans and ,medicare ,advantage for ,america plans4 7,e7 ,the ,secretary shall semiannually review if the rates paid by ,medicare for ,america are creating barriers to care4 ,the ,secretary shall have the authority to raise rates as necessary to ensure adequate access to care4 7#d7 ,increased ,federal match for medicaid and the children's health insurance program for years #bjbc through #bjbg ,the ,secretary of ,health and ,human ,services shall pay the difference between the ,medicare for ,america rates and the ,medicaid and ,,chip rates during the period beginning on ,january #a1 #bjbc1 and ending on ,december #ca1 #bjbg4 7c7 ,participating providers 7#a7 ,in general ,a health care provider that is a participating provider of services or supplier under the ,medicare program under title ,,xviii or the ,medicaid program under title ,,xix on the date of enactment of this title shall remain a participating provider for ,medicare for ,america4 7#b7 ,additional providers ,the ,secretary shall establish a process to allow health care providers not described in paragraph 7#a7 to become participating providers for ,medicare for ,america4 7d7 ,prescription drugs 7#a7 ,in general ,notwithstanding any other provision of law1 the ,secretary shall1 for plan years beginning on or after the date of the enactment of this title1 negotiate with pharmaceutical manufacturers the prices 7including discounts1 rebates1 and other price concessions7 that may be charged to ,medicare for ,america and ,,ma for ,america organizations during a negotiated price period 7as specified by the ,secretary7 for covered drugs for ,medicare for ,america enrollees4 ,in negotiating such prices under this section1 the ,secretary shall take into account the following factors3 7,a7 ,the comparative clinical effectiveness and cost effectiveness1 when available from an impartial source1 of such drug4 7,b7 ,the budgetary impact of providing coverage of such drug4 7,c7 ,the number of similarly effective drugs or alternative treatment regimens for each approved use of such drug4 7,d7 ,the associated financial burden on patients that utilize such drug4 7,e7 ,the associated unmet patient need for such drug4 7,f7 ,the total revenues from global sales obtained by the manufacturer for such drug and the associated investment in research and development of such drug by the manufacturer4 7#b7 ,finalization of negotiated price ,the negotiated price of each covered drug for a negotiated price period shall be finalized not later than #cj days before the first plan year in such negotiated price period4 7#c7 ,competitive licensing authority 7,a7 ,in general ,notwithstanding any exclusivity under clause 7iii7 or 7iv7 of section #eje7;j77#e77;,f7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act1 clause 7iii7 or 7iv7 of section #eje7;c77#c77;,e7 of such ,act1 section #cea7k77#g77;,a7 of the ,public ,health ,service ,act1 or section #ebg7;a7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act1 or by an extension of such exclusivity under section #eje;,a of such ,act or section #eje;,e of such ,act1 and any other provision of law that provides for market exclusivity 7or extension of market exclusivity7 with respect to a drug1 in the case that the ,secretary is unable to successfully negotiate an appropriate price for a covered drug for a negotiated price period1 the ,secretary shall authorize the use of any patent1 clinical trial data1 or other exclusivity granted by the ,federal ,government with respect to such drug as the ,secretary determines appropriate for purposes of manufacturing such drug for sale under ,medicare for ,america4 ,any entity making use of a competitive license to use patent1 clinical trial data1 or other exclusivity under this section shall provide to the manufacturer holding such exclusivity reasonable compensation1 as determined by the ,secretary based on the following factors3 7i7 ,the risk-adjusted value of any ,federal ,government subsidies and investments in research and development used to support the development of such drug4 7ii7 ,the risk-adjusted value of any investment made by such manufacturer in the research and development of such drug4 7iii7 ,the impact of the price1 including license compensation payments1 on meeting the medical need of all patients4 7iv7 ,the relationship between the price of such drug1 including compensation payments1 and the health benefits of such drug4 7v7 ,other relevant factors determined appropriate by the ,secretary to provide reasonable compensation4 7,b7 ,reasonable compensation ,the manufacturer described in subparagraph 7,a7 may seek recovery against the ,united ,states in the ,united ,states ,court of ,federal ,claims4 7,c7 ,interim period 7i7 ,in general ,until #a year after a drug described in subparagraph 7,a7 is approved under section #eje7;j7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act or section #cea7k7 of the ,public ,health ,service ,act and is provided under license issued by the ,secretary under such subparagraph1 ,medicare for ,america shall not pay more for such drug than the average of the prices available1 during the most recent #ab-month period for which data is available prior to the beginning of such negotiated price period1 from the manufacturer to any wholesaler1 retailer1 provider1 health maintenance organization1 nonprofit entity1 or governmental entity in the ten ,,oecd 7,organization for ,economic ,cooperation and ,development7 countries that have the largest gross domestic product with a per capita income that is not less than half the per capita income of the ,united ,states or the price established by the ,prescription ,drug and ,medical ,device ,review ,board established under title ,,iii of the ,medicare for ,america ,act of #bjai4 7ii7 ,federal program licensing ,if such drug is not made available at the price determined1 the ,secretary shall authorize such entities to use any patent1 clinical trial data1 or other exclusivity granted by the ,federal ,government with respect to such drug as the ,secretary determines appropriate for purposes of manufacturing such drug for sale under any ,federal program1 including those provided by ,medicare for ,america1 ,veterans ,affairs1 the ,department of ,defense1 and the ,coast ,guard4 7,d7 ,authorization for secretary to procure drugs directly 7i7 ,in general ,the ,secretary may procure a drug manufactured pursuant to a competitive license under subparagraph 7,a7 for purposes of this part or pursuant to a ,federal program license under subparagraph 7,c77ii7 for purposes of a ,federal program directly from the entity manufacturing the drug pursuant to such a license4 7ii7 ,clarification regarding application of buy american act ,in the case where the ,secretary procures a drug under this subparagraph1 the provisions of chapter #hc of title #da1 ,united ,states ,code 7commonly referred to as the ,buy ,american ,act71 shall apply4 7,e7 ,priority for u4s4 manufacturers in authorizing competitive licenses ,in authorizing a competitive license under this paragraph1 the ,secretary-- 7i7 shall give preference to entities that the ,secretary determines have the highest safety and security standards2 and 7ii7 may give priority to entities that will manufacture such drug in the ,united ,states4 7#d7 ,,fda review of licensed drug applications ,the ,secretary shall prioritize review of applications under section #eje7;j7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act for drugs licensed under paragraph 7#c77;,a74 7#e7 ,prohibition of anticompetitive behavior ,no drug manufacturer may engage in anticompetitive behavior with another manufacturer that may interfere with the issuance and implementation of a competitive license or run contrary to public policy4 7#f7 ,required reporting ,the ,secretary may require pharmaceutical manufacturers to disclose to the ,secretary such information that the ,secretary determines necessary for purposes of carrying out this subsection4 7#g7 ,clarification ,nothing in this subsection shall be construed as preventing ,medicare for ,america obtaining a discount or reduction of the price for a covered drug below the price negotiated by the ,secretary4 7#h7 ,value or cost-effectiveness assessments ,the use of ,quality-,adjusted ,life ,years1 ,disability-,adjusted ,life ,years1 or other similar mechanisms is prohibited for use in value or cost-effectiveness assessments for purposes of this subsection4 7#i7 ,clarification ,there shall be no formulary under ,medicare for ,america4 #bbjg4 ,trust fund2 funding 7a7 ,trust fund ,there shall be established a unified ,medicare ,trust ,fund in which funds provided under this title are deposited and from which expenditures under this title are made4 ,the ,trust ,fund shall consist of such gifts and bequests as may be made and such amounts as may be deposited in1 or appropriated to1 such ,trust ,fund as provided in this ,act4 7b7 ,funding 7#a7 ,taxes ,there are hereby appropriated to the ,trust ,fund for each fiscal year beginning with fiscal year #bjbc1 out of any moneys in the ,treasury not otherwise appropriated1 amounts equivalent to #ajj percent of the net increase in revenues to the ,treasury which is attributable to the amendments made by title ,,ii of the ,medicare for ,america ,act and premiums collected under this title4 ,the amounts appropriated by the preceding sentence shall be transferred from time to time 7but not less frequently than monthly7 from the general fund in the ,treasury to the ,trust ,fund1 such amounts to be determined on the basis of estimates by the ,secretary of the ,treasury of the taxes paid to or deposited into the ,treasury2 and proper adjustments shall be made in amounts subsequently transferred to the extent prior estimates were in excess of or were less than the amounts that should have been so transferred4 7#b7 ,current program receipts ,notwithstanding any other provision of law1 there are hereby appropriated to the ,trust ,fund for each fiscal year1 beginning with fiscal year #bjbc1 the amounts that would otherwise have been appropriated to carry out the following programs3 7,a7 ,the ,medicare program under title ,,xviii4 7,b7 ,the ,medicaid program under title ,,xix1 beginning as of #bjbg4 7#c7 ,additional appropriations ,additional sums are authorized to be appropriated annually as needed to maintain maximum quality1 efficiency1 and access under this part4 7#d7 ,medicaid maintenance of effort payments ,there shall be transferred to the ,trust ,fund the maintenance of effort payments made under section #bbji4 7c7 ,restrictions shall not apply ,any other provision of law in effect on the date of enactment of this title restricting the use of ,federal funds for any reproductive health service1 including abortion1 shall not apply to monies in the ,trust ,fund4 7d7 ,incorporation of provisions ,the provisions of subsections 7b7 through 7i7 of section #ahag shall apply to the ,trust ,fund under this section in the same manner as such provisions applied to the ,federal ,hospital ,insurance ,trust ,fund under such section #ahag1 except that1 for purposes of applying such subsections to this section1 the ,board of ,trustees of the ,trust ,fund shall mean the ,secretary4 7e7 ,transfer of funds ,any amounts remaining in the ,federal ,hospital ,insurance ,trust ,fund under section #ahag or the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda after the payment of claims for items and services furnished under title ,,xviii have been completed1 shall be transferred into the ,trust ,fund under this section4 #bbjh4 ,administrative provisions 7a7 ,center for health care ,beginning #bjbc1 the ,centers for ,medicare ,medicaid ,services shall be renamed the ,center for ,health ,care and all references in law and regulation to such ,centers shall be deemed a reference to such ,center4 ,all powers1 duties1 and responsibilities of the ,centers for ,medicare ,medicaid ,services shall be transferred to the ,center for ,health ,care4 7b7 ,authority ,the ,secretary shall have the authority to issue interim final rules with respect to any provision in this part4 7c7 ,administrative law judges 7#a7 ,in general ,the ,center for ,health ,care is not authorized to appoint administrative law judges1 in accordance with pages #aadbj through #aadii of title #gj of the ,federal ,register 7,march #h1 #bjje74 7#b7 ,timing ,under this title1 administrative law judges must issue a decision within #ij days of receipt of a hearing request1 as specified in subsections 7a7 and 7c7 of section #dje4ajaf of title #b1 ,code of ,federal ,regulations4 7d7 ,coverage determinations appeals 7#a7 ,individuals may appeal a coverage determination under this title before the individual obtains the service or item that is the subject of the appeal4 ,individuals shall continue to receive the service or item if an appeal is filed before the provision of the service or item is terminated4 7#b7 ,the ,secretary shall eliminate the redetermination by a ,medicare administrative contractor from the appeals process under the ,medicare program for beneficiaries4 7e7 ,private right of action 7#a7 ,in general ,an applicant or recipient denied a right conferred by this title may bring a civil action seeking any remedy available in law or equity to remedy that violation4 ,state courts and district courts of the ,united ,states shall have concurrent jurisdiction of such actions4 7#b7 ,right defined ,rights are created by any provision of this title that-- 7,a7 prescribes1 establishes1 or confers a benefit or protection in favor of the individual or individuals seeking to enforce the provision2 or 7,b7 prescribes1 establishes1 or imposes a duty or obligation on a person or entity to act or conduct operations in a manner that benefits the individual or individuals seeking to enforce the provision4 7#c7 ,reasonable attorney fees ,in any action or proceeding to enforce this title1 the court may award reasonable attorneys' fees and litigation costs 7including expert fees7 reasonably incurred against the defendant or defendants4 7#d7 ,appeal ,any civil action brought under this section shall be subject to appeal as provided in sections #abia and #abib of title #bh of the ,united ,states ,code4 7#e7 ,continued application of other laws ,nothing in this title 7or an amendment made by this title7 shall be construed to invalidate or limit the rights1 remedies1 procedures1 or legal standards available to individuals aggrieved under section #aigi of the ,revised ,statutes 7#db ,u4,s4,c4 #aihc71 or to supersede ,state laws causes of action4 7f7 ,non-,discrimination 7#a7 ,in general ,except as otherwise provided for in this title1 an individual shall not1 on the ground prohibited under title ,,vi of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;d et seq471 title ,,ix of the ,education ,amendments of #aigb 7#bj ,u4,s4,c4 #afha et seq471 the ,age ,discrimination ,act of #aige 7#db ,u4,s4,c4 #faja et seq471 section #ejd of the ,rehabilitation ,act of #aigc 7#bi ,u4,s4,c4 #gid71 or section #aeeg of the ,affordable ,care ,act 7#db ,u4,s4,c4 #ahaaf71 be excluded from participation in1 be denied the benefits of1 or be subjected to discrimination under1 any health program or activity1 any part of which is receiving ,federal financial assistance1 including credits1 subsidies1 or contracts of insurance1 or under any program or activity that is administered by an ,executive ,agency or any entity established under this title 7or amendments7 or any employer-sponsored insurance4 ,the enforcement mechanisms provided for and available under such title ,,vi1 title ,,ix1 section #gid1 ,age ,discrimination ,act1 or such section #aeeg shall apply for purposes of violations of this subsection4 7#b7 ,continued application of laws ,nothing in this title 7or an amendment made by this title7 shall be construed to invalidate or limit the rights1 remedies1 procedures1 or legal standards available to individuals aggrieved under title ,,vi of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;d et seq471 title ,,vii of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;e et seq471 title ,,ix of the ,education ,amendments of #aigb 7#bj ,u4,s4,c4 #afha et seq471 section #ejd of the ,rehabilitation ,act of #aigc 7#bi ,u4,s4,c4 #gid71 the ,age ,discrimination ,act of #aige 7#db ,u4,s4,c4 #faa et seq471 or section #aeeg of the ,affordable ,care ,act 7#db ,u4,s4,c4 #ahaaf7 or to supersede ,state laws that provide additional protections against discrimination on any basis described in paragraph 7#a74 7#c7 ,health care providers ,health care providers may not be prohibited from participating in the ,medicare for ,america for reasons other than their ability to provide covered services4 ,health care providers and institutions are prohibited from denying covered individuals access to covered benefits and services because of their religious objections4 ,this subsection supercedes any provision of law that allows for conscience protection4 7#d7 ,regulations ,the ,secretary may promulgate regulations to implement this subsection4 #bbji4 ,maintenance of effort requirement 7a7 ,in general ,a ,state is not eligible for payment under any program specified in subsection 7c7 for a calendar quarter in a plan year beginning after #bjbg unless the ,state makes to the ,secretary for transfer to the unified ,medicare ,trust ,fund under section #bbjg the maintenance of effort payment applicable to such ,state and plan year under subsection 7b74 ,the ,secretary shall extend such a waiver 7including the availability of ,federal financial participation under such waiver7 for such period as may be required for a ,state to meet the requirement of the previous sentence4 7b7 ,maintenance of effort payments ,for purposes of this section1 a maintenance of effort payment with respect to a ,state and plan year is-- 7#a7 for plan year #bjbh and a ,state1 a payment in an amount equal to the total amount of expenditures of the ,state for medical assistance under title ,,xix and child health assistance under title ,,xxi including administrative costs for the plan year before the date of the enactment of this title2 7#b7 for plan year #bjbi and each subsequent plan year before plan year #bjcc-- 7,a7 in the case of a ,state that is a ,,ppaca expansion ,state1 the payment amount applied under this subsection for the previous plan year1 increased by growth in ,,gdp per capita plus #j4d percent2 and 7,b7 in the case of a ,state that is not a ,,ppaca expansion ,state1 the payment amount applied under this subsection for the previous plan year1 increased by growth in ,,gdp per capita plus #j4g percent2 and 7#c7 beginning in #bjcc1 for each subsequent plan year1 with respect to any ,state1 the payment amount applied under this subsection for the previous year1 increased by growth in ,,gdp per capita plus #j4g percent4 7c7 ,programs specified ,for purposes of this section1 the programs specified in this subsection are each of the following3 7#a7 ,block grants for community mental health services under subpart ,i of part ,b of title ,,xix of the ,public ,health ,service ,act4 7#b7 ,block grants and programs for social services and elder justice under title ,,xx4 7#c7 ,maternal and child health services block grants under title ,v4 7#d7 ,block grants for prevention and treatment of substance abuse under subpart ,,ii of part ,b of title ,,xix of the ,public ,health ,service ,act4 7#e7 ,state ,targeted ,response to ,opioid ,crisis ,grant ,community ,services ,block ,grant4 7#f7 ,grants under section #ccj of the ,public ,health ,service ,act4 7#g7 ,ryan ,white ,,hiv_/,,aids ,program grants under title ,,xxvi of the ,public ,health ,service ,act4 #bbaj4 ,application of title ,,xviii provisions ,except as specified otherwise in this title1 in implementing ,medicare for ,america1 the ,secretary shall to the greatest extent practicable apply the following provisions of title ,,xviii to the program under this title1 benefits covered under this title1 individuals entitled to benefits under this title1 and providers of services and suppliers participating under the program under this title in a similar manner as such provisions applied to the program under title ,,xviii1 benefits covered under such title1 individuals entitled to benefits or enrolled under such title1 and providers of services and suppliers participating under the program under such title3 7#a7 ,section #ahja4 7#b7 ,section #ahje4 7#c7 ,section #ahjf4 7#d7 ,section #ahjg4 7#e7 ,section #ahji4 7#f7 ,section #ahad4 7#g7 ,section #ahae4 7#h7 ,section #ahaf4 7#i7 ,section #ahah4 7#aj7 ,section #ahah;,a4 7#aa7 ,section #ahai4 7#ab7 ,section #ahbj4 7#ac7 ,section #ahcd4 7#ad7 ,section #ahcd;,a4 7#ae7 ,section #ahdc4 7#af7 ,section #ahdf4 7#ag7 ,section #ahdg4 7#ah7 ,section #ahea4 7#ai7 ,section #aheb4 7#bj7 ,section #ahee4 7#ba7 ,section #ahef4 7#bb7 ,section #aheg4 7#bc7 ,section #aheh4 7#bd7 ,section #ahfa4 7#be7 ,section #ahfc4 7#bf7 ,section #ahfd4 7#bg7 ,section #ahff;,b4 7#bh7 ,section #ahff;,c4 7#bi7 ,section #ahff;,e4 7#cj7 ,section #ahfg4 7#ca7 ,section #ahfh4 7#cb7 ,section #ahfi4 7#cc7 ,section #ahga4 7#cd7 ,section #ahgd;,a4 7#ce7 ,section #ahhj4 7#cf7 ,section #ahha4 7#cg7 ,section #ahha;,a4 7#ch7 ,section #ahia4 7#ci7 ,section #ahid4 7#dj7 ,section #ahie4 7#da7 ,section #ahif4 ,b ,home and ,community ,based ,long-,term ,services and ,supports #bbca4 ,home and community based long-term services and supports benefit ,all individuals enrolled under ,medicare for ,america under this title shall have coverage for home and community based long-term services and supports benefits4 ,nothing in this part shall be construed to limit an enrollee's entitlement to any other benefit that is covered pursuant to section #bbjc1 including nursing facility benefits4 #bbcb4 ,eligibility 7a7 ,eligible individuals ,an individual who is eligible for home and community based long-term services and supports benefits under this part is an individual who satisfies each of the following3 7#a7 ,the individual is eligible for ,medicare for ,america4 7#b7 ,the individual is determined by a licensed health care practitioner to be unable to perform1 without substantial assistance1 at least one ,activity of ,daily ,living as described in section #ggjb;,b7c77#b77;,b7 of the ,internal ,revenue ,code of #aihf1 or to require substantial assistance with one or more of the following areas3 7,a7 ,communication4 7,b7 ,social interaction4 7,c7 ,learning4 7,d7 ,self-care4 7,e7 ,self-management4 7,f7 ,impairments that affect the person's capacity for social or economic participation4 7b7 ,clarification ,under this part1 in the case of an individual described in subsection 7a7 who experiences periods in which their functional capacity changes or improves1 such individual shall continue to have access to benefits under this part as needed4 ,if such an individual's functional capacity improves to a point in which the individual no longer requires home and community based long-term services and supports1 or requires fewer services1 the individual shall be able to immediately and seamlessly resume receiving all needed services if and when their functional needs recur4 ,eligibility for services shall be maintained if1 without the services1 the individual would have reduced functional capacity4 ,when assessing functional impairment1 the individual will be assessed without regard to any current services or the ameliorative effects of other mitigating measures described in section #c7d77;,e77i77,i7 of the ,americans ,with ,disabilities ,act of #aiij4 7c7 ,benefits 7#a7 ,definition ,for purposes of this title1 the term home and community based long-term services and supports benefit means the daily living supports needed by eligible individuals in order to live1 work1 and participate in their communities1 and includes all home and community based services and supports coverable as of the date of the enactment of this title1 under any ,state plan or waiver under title ,,xix1 including-- 7,a7 home health aides and homemakers2 7,b7 direct support professionals and personal attendant care services2 7,c7 hospice2 7,d7 nursing care2 7,e7 medical social services2 7,f7 care coordination1 including case management1 fiscal intermediary1 and support brokerage services2 7,g7 short-term inpatient care1 including respite care and care for pain control2 7,h7 behavioral health home and community based long-term services and supports1 including assertive community treatment2 peer support services2 intensive care coordination1 including case management2 supported employment2 and supported housing wraparound2 7,i7 private-duty nursing2 7,j7 respite services provided in the individual's home or broader community2 and 7,k7 transitional services to support an individual's transition from an institutional setting to the community4 7#b7 ,non-application ,the provisions of sections #dbd4bb7;a77#a77;i7 and #dbd4bb7;a77#a77;ii7 of title #db of the ,code of ,federal ,regulations does not apply in the case of the benefit described in paragraph 7#a77;,a74 7d7 ,home and ,community ,based ,long-,term ,services and ,supports ,workforce ,development 7#a7 ,in general ,the ,secretary shall ensure that the number of individuals in the home and community based long-term services and supports workforce is adequate to ensure community integration for all beneficiaries under ,medicare for ,america4 ,in so doing1 the ,secretary may consider a wide range of factors1 including payment rates for direct care workers1 career pipelines and credentialing1 worker rights1 and the impact of national labor policies4 7#b7 ,self-directed model ,all eligible individuals shall be defaulted into a self-directed care option 7as defined by the ,secretary74 ,the ,secretary must consult with eligible individuals1 caregivers1 workers and their representatives1 including unions1 and state entities responsible for administering the ,,ltss benefit to establish this model4 7#c7 ,community first ,the benefit under this part shall be arranged for and provided with a community first presumption and eligible individuals shall be provided home and community based long-term services and support available under this section1 regardless of type or level of disability or service need4 ,no eligible individual may be referred to an institution without first being offered and1 if chosen1 provided home and community based long-term services and supports4 ,individuals in an institution on the effective date of the bill1 and at least annually or upon any change in condition thereafter1 shall be informed of1 and if chosen1 provided with home and community based long-term services and supports4 7e7 ,administration of ,services and ,supports ,state entities responsible for administering home and community based long-term services and support benefits under any ,state plan or waiver under title ,,xix as of the date of the enactment of this title shall continue to administer the benefits and services coverable under this section4 7f7 ,coordination with other ,federal benefits 7#a7 ,rule of construction ,nothing in this part shall be construed as prohibiting benefits paid under this part from being used to compensate a caregiver who provides community living assistance services and supports to a dependent relative for providing community living assistance services and supports to an eligible individual under this part4 7#b7 ,dependent relative defined ,the term dependent relative means a child1 grandchild1 niece1 nephew1 parent1 grandparent1 sibling1 aunt1 or uncle 7of such caregiver or his or her spouse or domestic partner72 such caregiver's spouse or domestic partner1 if such child1 grandchild1 niece1 nephew1 parent1 grandparent1 sibling1 aunt1 uncle1 spouse1 or domestic partner is an eligible individual4 7#c7 ,supplement not supplant ,benefits received under this part by a caregiver shall supplement1 but not supplant1 other benefits for which the individual is eligible under any other federally funded program that provides benefits or assistance4 7#d7 ,disregard ,the benefit paid under this part shall be disregarded for purposes of determining or continuing the eligibility of the individual or the spouse of the individual for receipt of benefits under any other ,federal1 ,state1 or locally funded assistance program1 including benefits paid under title ,,ii or ,,xvi1 under the laws administered by the ,secretary of ,veterans ,affairs1 under low-income housing assistance programs1 under the supplemental nutrition assistance program established under the ,food and ,nutrition ,act of #bjjh1 or under programs administered by ,state vocational rehabilitation agencies4 7#e7 ,regulations ,not later than one year after the date of the enactment of this section1 the ,secretary shall promulgate such regulations as are necessary to carry out this part and to prevent fraud and abuse with respect to the benefits under this part4 ,c ,,medicare ,,advantage ,,for ,,america #bbba4 ,all private plans 7a7 ,in general ,for plan years beginning with plan year #bjbc1 a health insurance issuer may offer health insurance coverage in the individual market only if such issuer has entered into a contract with the ,secretary under subsection 7b7 to offer such coverage4 7b7 ,agreements ,the ,secretary shall enter into an agreement with an ,,ma for ,america sponsor to offer ,,ma for ,america plans under this part for the coverage of individuals enrolled under ,medicare for ,america who elect to receive benefits under part ,a through such a plan4 7c7 ,,ma for ,america plan2 ,,ma for ,america sponsor ,for purposes of this part3 7#a7 ,,ma for ,america plan ,an ,,ma for ,america plan is a ,medicare ,advantage plan under part ,c of title ,,xviii1 except such plan shall provide coverage for individuals enrolled under ,medicare for ,america under part ,a of this title1 with respect to at least the benefits covered under such part ,a4 7#b7 ,,ma for ,america sponsor ,an ,,ma for ,america sponsor is a sponsor of an ,,ma for ,america plan4 #bbbb4 ,application of ,medicare ,advantage provisions ,for purposes of applying this part1 except as otherwise specified under this part1 the provisions of part ,c of title ,,xviii1 as in effect as of the date of the enactment of this title shall apply with respect to an ,,ma for ,america sponsor1 ,,ma for ,america plan1 individuals eligible for coverage under this part1 individuals enrolled under such plan1 and benefits covered under part ,a in a similar manner and to a similar extent as such provisions applied to an ,,ma organization1 ,,ma plan1 individuals eligible for under part ,c of such title1 individuals enrolled under an ,,ma plan1 and benefits covered under fee-for-service ,medicare as of such date4 #bbbc4 ,medicare ,advantage for ,america payment rates ,the rates for ,medicare ,advantage for ,america plans shall be equal to the rates paid by ,medicare for ,america4 ,the ,administrator of the ,center for ,healthcare shall pay ,medicare ,advantage for ,america plans #ie percent of average ,medicare for ,america costs in each county4 #bbbd4 ,separate premium for ,medicare ,advantage for ,america plans furnishing supplemental benefits ,nothing in this part shall preclude an individual from choosing a ,medicare ,advantage for ,america plan which requires the individual to pay an additional1 separate amount because of supplemental benefits or because it is a more expensive plan4 ,in such case the individual enrolled under such plan would be responsible for a separate monthly premium4 #bbbe4 ,prescription drug pricing under ,medicare ,advantage for ,america plans ,medicare ,advantage for ,america plans1 for prescription drugs1 shall pay no more than the price negotiated under ,medicare for ,america4 #bbbf4 ,ban on paying brokers' fees ,medicare ,advantage for ,america plans may not pay fees to insurance brokers4 #bbbg4 ,clarification on ,medicare ,advantage employer group waiver plans and the ,medicare secondary payer requirement ,such plans shall be exempt from the ,,msp ,requirement1 and nothing in this section shall be construed as prohibiting such plans from contributing to the payment of premiums and cost-sharing4 #bbbh4 ,references ,beginning in #bjbc1 all references in law and regulation to ,medicare ,advantage shall be deemed a reference to ,medicare ,advantage for ,america4 4 #aab4 ,modifications to and coordination with existing ,federal health programs 7a7 ,medicare1 ,medicaid1 and ,state children's health insurance program 7,,schip7 7#a7 ,in general ,notwithstanding any other provision of law1 subject to paragraphs 7#b7 and 7#c7 and section #bbjb7;c7 of the ,social ,security ,act1 as added by section #aaa-- 7,a7 no benefits shall be available under title ,,xviii of the ,social ,security ,act for any item or service furnished-- 7i7 beginning on or after ,january #a1 #bjbc 7except in the case of an individual enrolled under such title and title ,,xix of such ,act72 and 7ii7 beginning on or after ,january #a1 #bjbe1 with respect to all individuals1 including individuals enrolled under such title and title ,,xix of such ,act2 7,b7 no individual is entitled to medical assistance under a ,state plan approved under title ,,xix of such ,act-- 7i7 for any item or service furnished on or after ,january #a1 #bjbe1 in the case of an individual enrolled under such title and title ,,xviii of the ,social ,security ,act or an individual described in subclause 7,,viii7 of section #aijb7;a77#aj77;,a77i72 and 7ii7 for any item or service furnished on or after ,january #a1 #bjbg2 7,c7 no individual is entitled to medical assistance under a ,state child health plan under title ,,xxi of such ,act for any item or service furnished on or after ,january #a1 #bjbe2 and 7,d7 no payment shall be made to a ,state under section #aijc7;a7 or #baje7;a7 of such ,act with respect to medical assistance or child health assistance-- 7i7 for any item or service furnished on or after ,january #a1 #bjbe1 in the case of an individual enrolled under such title and title ,,xviii of the ,social ,security ,act or an individual described in subclause 7,,viii7 of section #aijb7;a77#aj77;,a77i72 and 7ii7 for any item or service furnished on or after ,january #a1 #bjbg4 7#b7 ,transition ,in the case of inpatient hospital services and extended care services during a continuous period of stay which began before ,january #a1 #bjbe1 for ,medicare and #bjbg for ,medicaid or ,,chip1 and which had not ended as of such date1 for which benefits are provided under title ,,xviii of the ,social ,security ,act1 under a ,state plan under title ,,xix of such ,act1 or under a ,state child health plan under title ,,xxi such ,act1 the ,secretary of ,health and ,human ,services shall provide for continuation of benefits under such title or plan until the end of the period of stay4 7b7 ,other ,federal health programs 7#a7 ,federal employees health benefits program ,nothing in this ,act1 or the amendments made by this ,act1 shall affect benefits made available under chapter #hi of title #e1 ,united ,states ,code4 7#b7 ,,tricare ,nothing in this ,act1 or the amendments made by this ,act1 shall affect benefits made available under sections #ajgi and #ajhf of title #aj1 ,united ,states ,code4 7#c7 ,treatment of benefits for veterans and ,native ,americans 7,a7 ,in general ,nothing in this ,act1 or the amendments made by this ,act1 shall affect the eligibility of veterans for the medical benefits and services provided under title #ch1 ,united ,states ,code1 or of ,indians for the medical benefits and services provided by or through the ,indian ,health ,service4 7,b7 ,reevaluation ,no reevaluation of the ,indian ,health ,service shall be undertaken without consultation with tribal leaders and stakeholders4 7,c7 ,supplemental ,indian ,health ,services allocation ,the ,secretary shall annually determine the need to provide an allotment of supplemental funds to ,indian ,health ,services1 including payments to providers1 health professional education1 administrative expenses1 and prevention and public health activities4 7#d7 ,enrollee choice ,nothing in this ,act shall preclude individuals enrolled in the ,federal ,employees ,health ,benefits ,program or ,,tricare or individuals receiving benefits provided under title1 #ch1 ,united ,states ,code or the ,indian ,health ,service from enrolling in ,medicare for ,america4 ,enrollees shall be entitled to the employer contribution as established under section #abf7;c7 of such ,act4 7c7 ,sunset of provisions related to the ,state exchanges ,effective ,january #a1 #bjbb1 the ,federal and ,state ,exchanges established pursuant to title ,i of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh7 shall terminate1 and any other provision of law that relies upon participation in or enrollment through such an ,exchange1 including such provisions of the ,internal ,revenue ,code of #aihf1 shall cease to have force or effect4 7d7 ,severability ,every provision in this ,act and every application of the provisions in this ,act are severable from each other as a matter of ,federal law4 ,if any application of any provision in this ,act to any person or group of persons or circumstances is found by a court to be invalid1 the remainder of this ,act and the application of the ,act's provisions to all other persons and circumstances may not be affected4 ,c ,targeted ,reforms #aba4 ,no surprise billing 7a7 ,surprise bill defined ,for purposes of this section the term surprise bill-- 7#a7 means a bill for health care services1 other than emergency services1 received by an insured for services rendered by an out-of-network health care provider1 where such services were rendered by such out-of-network provider at an in-network facility1 during a service or procedure performed by an in-network provider or during a service or procedure previously approved or authorized by the health carrier and the insured did not knowingly elect to obtain such services from such out-of-network provider2 and 7#b7 does not include a bill for health care services received by an insured when an in-network health care provider was available to render such services and the insured knowingly elected to obtain such services from another health care provider who was out-of-network4 7b7 ,no non-participating health care provider shall require prior authorization for rendering emergency services to an insured4 7c7 ,no health carrier shall impose1 for emergency services rendered to an insured by an out-of-network health care provider1 a coinsurance1 copayment1 deductible or other out-of-pocket expense that is greater than the coinsurance1 copayment1 deductible or other out-of-pocket expense that would be imposed if such emergency services were rendered by an in-network health care provider4 7d7 ,payment ,amount ,if emergency services were rendered to an insured by an out-of-network health care provider1 such health care provider may bill the health carrier directly and the health carrier shall reimburse such health care provider the greatest of the following amounts3 7#a7 ,the amount payable under ,medicare for ,america for such services if rendered by a health care provider participating in ,medicare for ,america4 7#b7 ,the arbitrated amount between the qualifying health plan and the non-participating provider4 7e7 ,nothing in this section shall be construed to prohibit the qualifying health plan and the non-participating health care provider from agreeing to a greater reimbursement amount4 7f7 ,non-,emergency services ,with respect to a surprise bill1 the following applies3 7#a7 ,an individual enrolled in the qualifying health plan shall only be required to pay the applicable coinsurance that would be imposed for such health care services if such services were rendered by a participating health care provider4 7#b7 ,the qualifying health plan shall reimburse the non-participating health care provider or individual enrolled in such health plan1 as applicable1 for health care services rendered at the qualifying health plane rate as payment in full1 unless the health plan and the non-participating health care provider agree otherwise4 7g7 ,if health care services were rendered to an individual enrolled in qualifying health coverage by a non-participating health care provider and the qualifying health plan failed to inform such enrollee1 if such enrollee was required to be informed1 of the network status of such non-participating health care provider1 the qualifying health plan shall not impose coinsurance expense that is greater than the maximum out-of-pocket expense that would be imposed if such services were rendered by a qualifying health care provider4 7h7 ,emergency services 7#a7 ,no prior authorization ,a health care provider not participating in ,medicare for ,america may not require prior authorization for rendering emergency services to an individual enrolled under ,medicare for ,america4 7#b7 ,out-of-pocket expenses ,a health care provider not participating in ,medicare for ,america may not impose1 for emergency services rendered to an individual enrolled in ,medicare for ,america1 a coinsurance1 copayment1 or other out-of-pocket expense that is greater than the coinsurance or maximum out-of-pocket expense that would be imposed if such emergency services were rendered by a ,medicare for ,america participating provider4 7#c7 ,payment amount ,if emergency services are rendered to an individual enrolled in ,medicare for ,america by a health care provider not participating in ,medicare for ,america1 such health care provider may bill ,medicare for ,america directly and ,medicare for ,america shall reimburse such health care provider the greatest of the following amounts3 7,a7 ,the amount payable under ,medicare for ,america for such services if rendered by a health care provider participating in ,medicare for ,america4 7,b7 ,the arbitrated amount between the ,secretary of ,health and ,human ,services and the provider1 determined by an arbitration process established by the ,secretary4 7i7 ,non-,emergency services ,with respect to a surprise bill1 the following applies3 7#a7 ,an individual enrolled in qualifying coverage 7as defined in section #bbjb7;b77#d77;,b7 of the ,social ,security ,act7 shall only be required to pay the applicable coinsurance that would be imposed for such health care services if such services were rendered by a health care provider participating in ,medicare for ,america4 7#b7 ,the ,secretary of ,health and ,human ,services shall reimburse the non-participating health care provider or individual enrolled in such health plan1 as applicable1 for health care services rendered at rate payable under ,medicare for ,america as payment in full1 unless the ,secretary and the non-participating health care provider agree otherwise4 7#c7 ,if health care services were rendered to an individual enrolled in ,medicare for ,america by a health care provider not participating in ,medicare for ,america and the ,secretary of ,health and ,human ,services failed to inform such enrollee1 if such enrollee was required to be informed1 of the network status of such non-participating health care provider1 the ,secretary shall not impose a coinsurance expense that is greater than the maximum out-of-pocket expense that would be imposed if such services were rendered by a provider participating in ,medicare for ,america4 #abb4 ,limitation on removal of ,medicare ,advantage providers by ,,ma organizations 7a7 ,limitation ,section #aheb7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;d77 is amended by adding at the end the following3 7#g7 ,limitation on removal of providers from ma plans by ma organizations 7,a7 ,removal of providers with cause ,beginning with plan year #bjbj1 except as provided in subparagraph 7,c71 an ,,ma organization offering an ,,ma plan may only remove a provider of services or a supplier from a network of such plan if the organization has cause to remove such provider or supplier4 7,b7 ,cause to remove providers 7i7 ,in general ,an ,,ma organization offering an ,,ma plan has cause to remove a provider of services or a supplier from a network of such plan if the ,secretary determines that the provider or supplier is-- 7,i7 medically negligent2 7,,ii7 in violation of any legal or contractual requirement applicable to the provider or supplier acting within the lawful scope of practice1 including any participation or other requirement applicable to such provider or supplier under this title or under any contractual term for such plan2 or 7,,iii7 otherwise unfit to furnish items and services in accordance with requirements of this title4 7ii7 ,consideration of cost to ma organizations ,for purposes of subparagraph 7,a71 cost to an ,,ma organization offering an ,,ma plan due to the participation of a provider of services or supplier in a network of such plan does not constitute cause for the ,,ma organization to remove such provider or supplier from the network mid-year1 and such cost may not be considered as a factor in favor of a determination that such organization has cause to remove the provider4 7,c7 ,exception ,with respect to each upcoming plan year1 beginning with plan year #bjbj an ,,ma organization offering an ,,ma plan may only remove a provider of services or supplier from a network of such plan for reasons not specified in subparagraph 7,b77i7 before the date that is #fj days before the first day of the annual coordinated election period for such plan year under section #ahea7;e77#c74 7,d7 ,notice and appeal process 7i7 ,in general ,any removal of a provider of services or supplier from a network of an ,,ma plan may occur only after the completion of a fair notice and appeal process that the ,secretary shall establish by regulation4 ,such process shall require the ,,ma organization to provide to such provider or supplier and to the ,secretary an explanation of the reason or reasons for the removal4 ,the ,secretary shall make this information publicly available4 7ii7 ,application 7,i7 ,application of new process ,in the case of a removal of a provider of services or supplier from a network of an ,,ma plan occurring on or after the effective date published in a final rule for such fair notice and appeal process1 such process shall apply in lieu of the process for the termination or suspension of a provider contract under section #dbb4bjb7;a7 of title #db1 ,code of ,federal ,regulations4 7,,ii7 ,continuation of old process ,in the case of a removal of a provider of services or supplier from a network of an ,,ma plan occurring before such effective date1 the process for the termination or suspension of a provider contract under section #dbb4bjb7;a7 of title #db1 ,code of ,federal ,regulations1 shall apply4 7,e7 ,participant notice and protection 7i7 ,notice to participants of provider removal ,not less than #fj days before the date on which a provider of services or supplier is removed from a network of an ,,ma plan1 the ,,ma organization offering such plan shall provide written notification of the removal to each individual enrolled in such plan receiving items or services from the provider or supplier during the plan year in effect on the date of removal or during the previous plan year4 ,such notification shall include at the minimum-- 7,i7 the names and telephone numbers of available in-network providers of services and suppliers offering items and services that are the same or similar to the items and services offered by the removed provider or supplier2 7,,ii7 information regarding the options available to an individual enrolled in such plan to request the continuation of medical treatment or therapy with the removed provider or supplier2 and 7,,iii7 one or more customer service telephone numbers that an individual enrolled in such plan may access to obtain information regarding changes to the network of the plan4 7ii7 ,annual notice of change ,in addition to providing the notification of removal as required under clause 7i71 the ,,ma organization offering such ,,ma plan shall include such notification in the annual notice of change for the ,,ma plan for the upcoming plan year4 7iii7 ,continuity of care ,in any case in which a provider of services or supplier is removed from a network of an ,,ma plan1 such plan shall ensure that the removal satisfies the continuity of care requirements under paragraph 7#a77;,a7 with respect to each individual enrolled in such plan receiving items or services from the provider or supplier during the plan year in effect on the date of removal or during the previous plan year4 7,f7 ,rule of construction ,nothing in this paragraph shall be construed as affecting the ability of a provider of services or supplier to decline to participate in a network of an ,,ma plan4 7#h7 ,transparency in measures used by ma organizations to establish or modify provider networks 7,a7 ,in general ,beginning with plan year #bjbj1 an ,,ma organization offering an ,,ma plan shall publish and make accessible the information described in subparagraph 7,b7-- 7i7 in the annual bid information submitted by the ,,ma organization with respect to the ,,ma plan under section #ahed2 and 7ii7 on the ,internet ,web ,site for the ,,ma plan4 7,b7 ,information described ,the information described in this subparagraph is the following3 7i7 ,information regarding the measures used by the ,,ma organization to establish or modify the provider network of the ,,ma plan1 including measures of the quality and efficiency of providers4 ,such information shall include the specifications1 methodology1 and sample size of such measures4 7ii7 ,other information related to the establishment or modification of such provider network that the ,secretary determines appropriate4 7,c7 ,limitation ,the information described in subparagraph 7,b7 shall not include any individually identifiable information of any provider or supplier of services4 4 7b7 ,enforcement 7#a7 ,sanctions for noncompliance ,section #aheg7;g77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;g77#a77 is amended-- 7,a7 in subparagraph 7,j71 by striking or2 7,b7 by redesignating subparagraph 7,k7 as subparagraph 7,l72 7,c7 by inserting after subparagraph 7,j7 the following new subparagraph3 7,k7 fails to comply with section #aheb7;d77#g7 or #aheb7;d77#h72 or 2 and 7,d7 in subparagraph 7,l7 7as so redesignated71 by striking through 7,j7 and inserting through 7,k74 7#b7 ,sanctions not applicable to part ,d ,title ,,xviii of the ,social ,security ,act is amended-- 7,a7 in section #ahfj;,d-#ab7;b77#c77;,e7 7#db ,u4,s4,c4 #aciew-#aab7;b77#c77;,e771 by striking paragraph 7#a77;,f7 and inserting paragraphs 7#a77;,f7 and 7#a77,k72 and 7,b7 in section #ahid7;e77#f77;,b7 7#db ,u4,s4,c4 #acie;eee7e77#f77;,b771 by inserting 7other than paragraph 7#a77,k7 of such section7 after #aheg7;g77#a74 7c7 ,medicare advantage plan compare tool ,not later than one year after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services shall take such measures as are necessary to ensure that the ,medicare ,advantage ,compare ,tool takes into account the preferences and utilization needs of such individuals4 #abc4 ,network adequacy 7a7 ,in general ,section #aheb7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;d77 is amended by adding at the end the following3 7#i7 ,network adequacy requirements ,beginning in plan year #bjai1 notwithstanding any other provision of law1 the following shall apply3 7,a7 ,provider availability ,when establishing a plan network1 a ,medicare ,advantage organization offering an ,,ma plan shall1 among other factors determined by the ,secretary1 consider the following3 7i7 ,the anticipated enrollment in the plan4 7ii7 ,the expected types of services provided and utilization of services by enrollees under the plan4 7iii7 ,the number and types of providers needed to provide such services4 7iv7 ,the number of network providers who are not accepting new patients4 7v7 ,the location of providers and enrollees1 taking into account geographic disbursement4 7vi7 ,the full-time equivalent availability of a provider to provide such services4 7,b7 ,provision of care in a timely manner ,a ,medicare ,advantage organization offering an ,,ma plan shall ensure that providers are able to provide services in a timely manner1 as defined by the ,secretary1 under the plan4 7,c7 ,application of network access adequacy standards ,in applying the network access adequacy standards pursuant to paragraph 7#a71 the ,secretary shall seek input from patient advocacy groups1 providers of services and suppliers1 and ,,ma plans under this part4 7,d7 ,certification ,each plan year1 a ,medicare ,advantage organization shall certify to the ,secretary1 with respect to each ,,ma plan offered by the organization1 that the providers1 including specialists and subspecialists1 in the plan network are able to provide the services required under the organization's contract with the ,secretary under section #aheg with respect to the offering of such plan and to meet the needs of the enrollees within the plan service area during the year4 7,e7 ,annual reporting ,each plan year1 a ,medicare ,advantage organization shall report to the ,secretary1 and make public the following with respect to each ,,ma plan offered by the organization3 7i7 ,average wait time ,the average wait time for primary and specialty care for enrollees under the plan4 7ii7 ,utilization of out of network providers ,the utilization of out-of-network providers under the plan4 7iii7 ,average cost per patient ,the average annual spending per patient for primary and specialty care for enrollees under the plan4 7,f7 ,certification ,in advance of the annual1 coordinated election period under section #ahea7;e77#c71 a ,medicare ,advantage organization shall certify to the ,secretary the accuracy of provider directories for each plan offered by the organization4 7,g7 ,network review ,the ,secretary shall ensure that the network of each ,,ma plan offered by a ,medicare ,advantage organization meets the network adequacy guidelines established under this paragraph and under section #dbb4aab7;a77#d7 of title #db1 ,code of ,federal ,regulations 7or any successor regulation to such section7 at least once every #c years or when a material change in network occurs4 7,h7 ,authority ,the ,secretary shall have the authority to stop any further enrollment in a ,medicare ,advantage plan if there is a pattern of excessive violations of this paragraph4 4 7b7 ,enforcement ,section #aheg7;g77#a77,k7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;g77#a77,k771 as added by section #b7;b71 is amended by striking or #aheb7;d77#h7 and inserting 1 #aheb7;d77#h71 or #aheb7;d77#i74 #abd4 ,eliminating the #bd-month waiting period for ,medicare coverage for individuals with disabilities 7a7 ,in general ,section #bbf7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #dbf7;b77 is amended-- 7#a7 in paragraph 7#b77;,a71 by striking 1 and has for #bd calendar months been entitled to12 7#b7 in paragraph 7#b77;,b71 by striking 1 and has been for not less than #bd months12 7#c7 in paragraph 7#b77;,c77ii71 by striking 1 including the requirement that he has been entitled to the specified benefits for #bd months12 7#d7 in the first sentence1 by striking for each month beginning with the later of 7,i7 ,july #aigc or 7,,ii7 the twenty-fifth month of his entitlement or status as a qualified railroad retirement beneficiary described in paragraph 7#b71 and and inserting for each month for which the individual meets the requirements of paragraph 7#b71 beginning with the month following the month in which the individual meets the requirements of such paragraph1 and2 and 7#e7 in the second sentence1 by striking the twenty-fifth month of his entitlement and all that follows through paragraph 7#b77;,c7 and4 7b7 ,conforming amendments 7#a7 ,section #bbf ,section #bbf of the ,social ,security ,act 7#db ,u4,s4,c4 #dbf7 is amended by-- 7,a7 striking subsections 7e77#a77;,b71 7f71 and 7h72 and 7,b7 redesignating subsections 7g7 and 7i7 as subsections 7f7 and 7g71 respectively4 7#b7 ,medicare description ,section #ahaa7b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;c7#b77 is amended by striking have been entitled for not less than #bd months and inserting are entitled4 7#c7 ,medicare coverage ,section #ahcg7;g77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciep7g77#a77 is amended by striking #beth month of and inserting month following the first month of4 7#d7 ,railroad retirement system ,section #g7;d77#b77;ii7 of the ,railroad ,retirement ,act of #aigd 7#de ,u4,s4,c4 #bca;f7d77#b77;ii77 is amended-- 7,a7 by striking has been entitled to an annuity and inserting is entitled to an annuity2 7,b7 by striking 1 for not less than #bd months2 and 7,c7 by striking could have been entitled for #bd calendar months1 and4 7c7 ,effective date ,the amendments made by this section shall apply to insurance benefits under title ,,xviii of the ,social ,security ,act with respect to items and services furnished in months beginning after the date of enactment of this ,act4 #abe4 ,eliminating the waiting period for individuals on ,state ,medicaid waiting lists ,the ,secretary of ,health and ,human ,services is appropriated such sums as are necessary to facilitate enrollment1 not later than #ij days after the date of the enactment of this ,act1 all eligible individuals who1 as of the date of the enactment of this ,act1 are on ,state ,medicaid waiting lists or ,state ,medicaid waiver waiting lists4 #abf4 ,employer health plan options 7a7 ,definition ,a qualifying employer-sponsored plan is-- 7#a7 a governmental plan 7within the meaning of section #bgia7;d77#h7 of the ,public ,health ,service ,act72 or 7#b7 any other plan or coverage that meets the criteria under subsection 7b71 includes vision1 dental1 and hearing benefits1 and provides health coverage that is equivalent to an actuarial value of at least #hj percent of the coverage provided under title ,,xxii of the ,social ,security ,act and makes a premium contribution of at least #gj percent4 ,such plan shall require a premium contribution from the employer of at least #gj percent regardless of whether coverage is for single1 spousal1 or dependent care4 7b7 ,obligation ,large employers shall1 with respect to any full-time employee of such employer-- 7#a7 offer a qualifying employer-sponsored plan to such employee1 in accordance with subsection 7a72 or 7#b7 make a contribution of #h percent of their annual payroll to the ,medicare ,trust ,fund under title ,,xxii of the ,social ,security ,act4 7c7 ,employee choice ,an employee may opt out of a qualifying employer-sponsored plan as satisfied by subsection 7b77#a7 in order to enroll in ,medicare for ,america4 ,the employer shall make a contribution equal to the contribution it shall make in order to meet the requirements established by subsection 7a77#a7 or 7a77#b74 ,the ,secretary of ,health and ,human ,services shall have authority to set standards for determining whether employers or insurers are undertaking any actions to affect the risk pool within ,medicare for ,america by inducing individuals to decline coverage under a qualifying employer-sponsored plan and instead to enroll in ,medicare for ,america4 ,an employer violating such standards shall be treated as not meeting the requirements of subsection 7a74 7d7 ,employee ,education on ,health ,coverage ,options ,large employers shall disseminate to employees such publicly available information on coverage options under ,medicare for ,america as the ,secretary deems appropriate1 including contact information for assistance4 7e7 ,special rules 7#a7 ,annual payroll ,for purposes of this paragraph1 the term annual payroll means1 with respect to any employer for any calendar year1 the aggregate wages paid by the employer during such calendar year4 7#b7 ,aggregation rules ,related employers and predecessors shall be treated as a single employer for purposes of this subsection4 7#c7 ,reduction for part-time employees ,in the case of a part-time employee1 the employer contribution requirements of paragraph 7#a7 shall be treated as satisfied if the employer contribution with respect to such employee is not less than the part-time employment ratio of the contribution required under paragraph 7#a74 7#d7 ,rules related to part-time employment ,for purposes of this subsection-- 7,a7 ,part-time employee ,the term part-time employee means1 with respect to any month1 an employee who works on average fewer than #cj hours per week4 7,b7 ,part-time employment ratio ,the term part-time employment ratio means1 with respect to a part-time employee of an employer in a month1 a fraction-- 7i7 the numerator of which is the number of hours in the employee's normal work week2 and 7ii7 the denominator of which is #cj hours4 7,c7 ,special rules ,under rules prescribed by the ,secretary of ,health and ,human ,services1 in consultation with the ,secretary of the ,treasury1 in the case of an employee for an employer whose defined work week for full-time employees is less than #cj hours1 any reference in this subsection to #cj hours is deemed a reference to the number of hours in the work week so defined4 7,d7 ,conversion to hours of employment ,the ,secretary of ,health and ,human ,services1 in consultation with the ,secretary of the ,treasury1 shall establish rules for the conversion of compensation to hours of employment1 for purposes of this subsection in the case of employees that receive compensation on a salaried basis1 or on the basis of a commission1 or other contingent or bonus basis1 rather than based on an hourly wage4 7f7 ,timing and manner ,each employer that makes a financial contribution under subsection 7b77#b7 and 7c7 under this section 7other than with respect to coverage under a group health plan7 shall pay such contribution in a form and manner1 specified by the ,secretary of the ,treasury1 based upon the form and manner in which employer excise taxes are required to be paid under section #caaa of the ,internal ,revenue ,code of #aihf4 7g7 ,non-,discrimination 7#a7 ,in general ,except as otherwise provided for in this title 7or an amendment made by this title71 an individual shall not1 on the ground prohibited under title ,,vi of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;d et seq471 title ,,ix of the ,education ,amendments of #aigb 7#bj ,u4,s4,c4 #afha et seq471 the ,age ,discrimination ,act of #aige 7#db ,u4,s4,c4 #faja et seq471 or section #ejd of the ,rehabilitation ,act of #aigc 7#bi ,u4,s4,c4 #gid71 be excluded from participation in1 be denied the benefits of1 or be subjected to discrimination under1 any health program or activity1 any part of which is receiving ,federal financial assistance1 including credits1 subsidies1 or contracts of insurance1 or under any program or activity that is administered by an ,executive ,agency or any entity established under this title 7or amendments7 or any employer-sponsored insurance4 7#b7 ,continued application of laws ,nothing in this title 7or an amendment made by this title7 shall be construed to invalidate or limit the rights1 remedies1 procedures1 or legal standards available to individuals aggrieved under title ,,vi of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;d et seq471 title ,,vii of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;e et seq471 title ,,ix of the ,education ,amendments of #aigb 7#bj ,u4,s4,c4 #afha et seq471 section #ejd of the ,rehabilitation ,act of #aigc 7#bi ,u4,s4,c4 #gid71 or the ,age ,discrimination ,act of #aige 7#db ,u4,s4,c4 #faa et seq471 or to supersede ,state laws that provide additional protections against discrimination on any basis described in paragraph 7#a74 7#c7 ,limitation ,a group health plan may not establish rules relating to the health insurance coverage eligibility 7including continued eligibility7 or contribution requirements of any full-time employee under the terms of the plan that have the effect of discriminating in favor of higher-wage employees4 7#d7 ,regulations ,the ,secretary of ,health and ,human ,services1 in conjunction with the ,secretary of ,labor1 may promulgate regulations to implement this subsection4 #abg4 ,prohibition on step therapy and prior authorization under group health plans ,section #bgai;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is amended by adding at the end the following new subsection3 7e7 ,prohibition against step therapy and prior authorization ,beginning with the first plan year following the date of the enactment of this subsection1 a group health plan may not require a prior authorization determination for coverage of any benefit under such plan and may not apply treatment limitations through the use of step therapy protocols4 4 #abh4 ,medicare outpatient observation services ,section #ahfa7;i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7i77 is amended by adding at the end the following3 ,for purposes of this subsection1 an individual receiving outpatient observation services shall be deemed to be an inpatient during such period1 and the date such individual ceases receiving such services shall be deemed the hospital discharge date 7unless such individual is admitted as a hospital inpatient at the end of such period74 #abi4 ,abortion coverage ,notwithstanding any other provision of law1 ,federal funds may be used to provide for abortion services under any health program or activity4 #acj4 ,applicability of mental health parity ,section #bgbf of the ,public ,health ,service ,act shall apply to all health coverage in the same manner and to the same extent as such section applies to health insurance issuers and group health plans under title ,,xxvii of such ,act4 #aca4 ,student loan forgiveness for health care providers participating in ,medicare for ,america 7a7 ,in general ,beginning on the date after the date of the enactment of this ,act1 after the conclusion of each plan year1 the ,secretary of ,health and ,human ,services1 in conjunction with the ,secretary of ,education1 shall cancel the applicable percent specified in subsection 7b7 of the total amount due on any eligible ,federal ,loan made #bj years prior to date of enactment and any date after the date of enactment of this ,act for a borrower who is a ,medicare for ,america participating provider and submits an employment certification form described in subsection 7d74 7b7 ,applicable percent ,for purposes of subsection 7a71 the applicable percent is #aj percent of any eligible ,federal ,loan for each year the health care provider participates in ,medicare for ,america4 7c7 ,definitions ,in this section3 7#a7 ,eligible ,federal loan ,the term eligible ,federal loan means any loan made under part ,d of title ,,iv of the ,higher ,education ,act of #aife 7#bj ,u4,s4,c4 #ajhg;a74 7#b7 ,health care provider ,the term health care provider means a physician1 physician assistant1 registered nurse1 nurse practitioner1 advanced practice nurse1 licensed practical nurse1 psychologist1 mental health counselor1 marriage and family therapist1 direct care worker1 health social worker1 dentist1 dental hygienist1 pharmacist1 physical therapist1 occupational therapist1 or any other health care provider specified by the ,secretary of ,health and ,human ,services if the ,secretary determines such specification for purposes of this section is necessary to ensure workforce adequacy4 7#c7 ,medicare for america participating provider ,the term ,medicare for ,america participating provider means a health care provider that meets the definition of such term under section #aje or works at a participating provider or entity as defined under section #aje4 7d7 ,employment ,certification ,form 7#a7 ,in general ,in order to receive loan cancellation under this paragraph1 a borrower shall submit to the ,secretary of ,education an employment certification form that is developed by the ,secretary of ,education and includes self-certification of employment and a separate part for employer certification that indicates the dates of employment4 7#b7 ,deferment ,if a borrower submits to the ,secretary of ,education the employment certification form described in paragraph 7#a71 during the period in which the borrower is employed as a ,medicare for ,america participating provider for which loan cancellation is eligible under this section1 the borrower's eligible ,federal ,direct ,loan shall be placed in deferment4 7e7 ,interest canceled ,if a portion of a loan is canceled under this section for any year1 the entire amount of interest on such loan that accrues for such year shall be canceled4 7f7 ,regulations ,the ,secretary of ,health and ,human ,services and ,secretary of ,education may promulgate regulations to implement this section4 #acb4 ,clarification of the definition of pediatric medical necessity in qualifying group coverage 7a7 ,definition ,the following definition of pediatric medical necessity shall be incorporated into benefit standards of all plans subject to the requirements of section #acjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7 and all group plans by #bjbc4 7b7 ,development of definition ,pediatric medical necessity1 or pediatric medically necessary care1 shall be defined as health care interventions that are evidence based1 evidence informed1 or based on consensus advisory opinion and that are recommended by recognized health care professionals1 to promote optimal growth and development in a child and to prevent1 detect1 diagnose1 treat1 ameliorate1 or palliate the effects of physical1 genetic1 congenital1 developmental1 behavioral1 or mental conditions1 injuries1 or disabilities4 7c7 ,updates to definition ,the ,secretary of ,health and ,human ,services1 in consultation with experts in the field of pediatric care and key stakeholders1 including patient and family groups1 shall review and update this definition on a biennial basis1 consistent with up-to-date standards of pediatric healthcare practice that are based on-- 7#a7 the views of pediatric healthcare providers and experts practicing in relevant clinical areas2 7#b7 recommendations of medical-specialty societies1 other pediatric healthcare provider organizations1 and family and patient groups1 and 7#c7 credible scientific evidence published in peer-reviewed literature that is generally recognized by the relevant health care provider community4 #acc4 ,safe staffing requirements 7a7 ,minimum direct care registered nurse staffing requirements ,the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bja et seq47 is amended by adding at the end the following new title3 ,,xxxiv ,minimum ,direct ,care ,registered ,nurse ,staffing ,requirement #cdja4 ,minimum nurse staffing requirement 7a7 ,staffing plan 7#a7 ,in general ,a hospital shall implement a staffing plan that-- 7,a7 provides adequate1 appropriate1 and quality delivery of health care services and protects patient safety2 and 7,b7 is consistent with the requirements of this title4 7#b7 ,effective dates 7,a7 ,implementation of staffing plan ,subject to subparagraph 7,b71 the requirements under paragraph 7#a7 shall take effect on a date to be determined by the ,secretary1 but not later than #a year after the date of the enactment of this title4 7,b7 ,application of minimum direct care registered nurse-to-patient ratios ,the requirements under subsection 7b7 shall take effect as soon as practicable1 as determined by the ,secretary1 but not later than-- 7i7 #bjbc2 and 7ii7 in the case of a hospital in a rural area 7as defined in section #ahhf7;d77#b77;,d7 of the ,social ,security ,act71 #bjbe4 7b7 ,minimum direct care registered nurse-to-,patient ratios 7#a7 ,in general ,except as provided in paragraph 7#d7 and other provisions of this section1 a hospital's staffing plan shall provide that1 at all times during each shift within a unit of the hospital1 and with a full complement of ancillary and support staff1 a direct care registered nurse may be assigned to not more than the following number of patients in that unit3 7,a7 ,one patient in trauma emergency units4 7,b7 ,one patient in operating room units1 provided that a minimum of #a additional person serves as a scrub assistant in such unit4 7,c7 ,two patients in critical care units1 including neonatal intensive care units1 emergency critical care and intensive care units1 labor and delivery units1 coronary care units1 acute respiratory care units1 postanesthesia units1 and burn units4 7,d7 ,three patients in emergency room units1 pediatrics units1 stepdown units1 telemetry units1 antepartum units1 and combined labor1 deliver1 and postpartum units4 7,e7 ,four patients in medical-surgical units1 intermediate care nursery units1 acute care psychiatric units1 and other specialty care units4 7,f7 ,five patients in rehabilitation units and skilled nursing units4 7,g7 ,six patients in postpartum 7#c couplets7 units and well-baby nursery units4 7#b7 ,similar units with different names ,the ,secretary may apply minimum direct care registered nurse-to-patient ratios established in paragraph 7#a7 for a hospital unit referred to in such paragraph to a type of hospital unit not referred to in such paragraph if such type of hospital unit provides a level of care to patients whose needs are similar to the needs of patients cared for in the hospital unit referred to in such paragraph4 7#c7 ,application of ratios to hospital nursing practice standards 7,a7 ,in general ,a patient assignment may be included in the calculation of the direct care registered nurse-to-patient ratios required in this subsection only if care is provided by a direct care registered nurse and the provision of care to the particular patient is within that direct care registered nurse's competence4 7,b7 ,demonstration of unit-specific competence ,a hospital shall not assign a direct care registered nurse to a hospital unit unless that hospital determines that the direct care registered nurse has demonstrated current competence in providing care in that unit1 and has also received orientation to that hospital's unit sufficient to provide competent care to patients in that unit4 7,c7 ,duties of the assigned direct care registered nurse ,each patient shall be assigned to a direct care registered nurse who shall directly provide the assessment1 planning1 supervision1 implementation1 and evaluation of the nursing care provided to the patient at least every shift and has the responsibility for the provision of care to a particular patient within his or her scope of practice4 7,d7 ,nurse administrators and supervisors ,a registered nurse who is a nurse administrator1 nurse supervisor1 nurse manager1 charge nurse1 case manager1 or any other hospital administrator or supervisor1 shall not be included in the calculation of the direct care registered nurse-to-patient ratio unless that nurse has a current and active direct patient care assignment and provides direct patient care in compliance with the requirements of this section1 including competency requirements4 ,the exemption in this subsection shall apply only during the hours in which the individual registered nurse has the principal responsibility of providing direct patient care and has no additional job duties as would a direct care registered nurse4 7,e7 ,other personnel ,other personnel may perform patient care tasks based on their training and demonstrated skill but may not perform or assist in direct care registered nurse functions unless authorized to do in accordance with ,state scope of practice laws and regulations4 7,f7 ,temporary nursing personnel ,a hospital shall not assign any nursing personnel from temporary nursing agencies patient care to any hospital unit without such personnel having demonstrated competence on the assigned unit and received orientation to that hospital's unit sufficient to provide competent care to patients in that unit4 7,g7 ,ancillary and additional staffing ,the need for additional staffing of direct care registered nurses1 licensed vocational or practical nurses1 licensed psychiatric technicians1 certified nursing or patient care assistants1 or other licensed or unlicensed ancillary staff above the minimum registered nurse-to-patient ratios shall be based on the assessment of the individual patient's nursing care requirement1 the individual patient's nursing care plan1 and acuity level4 7#d7 ,restrictions 7,a7 ,prohibition against averaging ,a hospital shall not average the number of patients and the total number of direct care registered nurses assigned to patients in a hospital unit during any #a shift or over any period of time for purposes of meeting the requirements under this subsection4 7,b7 ,prohibition against imposition of mandatory overtime requirements ,a hospital shall not impose mandatory overtime requirements to meet the hospital unit direct care registered nurse-to-patient ratios required under this subsection4 7,c7 ,relief during routine absences ,a hospital shall ensure that only a direct care registered nurse who has demonstrated current competence to the hospital in providing care on a particular unit and has also received orientation to that hospital's unit sufficient to provide competent care to patients in that unit may relieve another direct care registered nurse during breaks1 meals1 and other routine1 expected absences from a hospital unit4 7,d7 ,application of direct care registered nurse-to-patient ratios in patient-acuity adjustable units ,patients shall be cared for only on units or patient care areas where the direct care registered nurse-to-patient ratios meet the level of intensity1 type of care1 and the individual requirements and needs of each patient4 ,notwithstanding paragraph 7#b71 hospitals that provide patient care in units or patient care areas that are acuity adaptable or acuity adjustable shall apply the direct care registered nurse-to-patient ratio required in this section for the highest patient acuity level or level of care in that unit or patient care area1 and shall comply with all other requirements of this section4 7,e7 ,use of video monitors ,a hospital shall not employ video monitors or any form of electronic visualization of a patient as a substitute for the direct observation required for patient assessment by the direct care registered nurse or required for patient protection4 ,video monitors or any form of electronic visualization of a patient shall not be included in the calculation of the direct care registered nurse-to-patient ratio required in this subsection and shall not replace the requirement of paragraph 7#c77;,d7 that each patient shall be assigned to a direct care registered nurse who shall directly provide the assessment1 planning1 supervision1 implementation1 and evaluation of the nursing care provided to the patient at least every shift and have the responsibility for the provision of care to a particular patient within his or her scope of practice4 7,f7 ,use of other technology ,a hospital shall not employ technology that substitutes for the assigned registered nurse's professional judgment in assessment1 planning1 implementation1 and evaluation of care4 7#e7 ,adjustment of ratios 7,a7 ,in general ,if necessary to protect patient safety1 the ,secretary may prescribe regulations that-- 7i7 increase minimum direct care registered nurse-to-patient ratios under this subsection to reduce the number of patients that may be assigned to each direct care nurse2 or 7ii7 add minimum direct care registered nurse-to-patient ratios for units not referred to in paragraphs 7#a7 and 7#b74 7,b7 ,consultation ,such regulations shall be prescribed after consultation with affected hospitals and registered nurses4 7#f7 ,ancillary and additional staffing 7,a7 ,in general ,the ,secretary may prescribe regulations requiring additional staffing of direct care registered nurses1 licensed vocational or practice nurses1 licensed psychiatric technicians1 certified nursing or patient care assistants1 or other licensed or unlicensed ancillary staff above the minimum registered nurse-to-patient ratios that is based on the assessment of the individual patient's nursing care needs1 the individual patient's nursing care plan1 and acuity level4 7,b7 ,consultation ,such regulations shall be prescribed after consultation with affected hospitals1 registered nurses1 and ancillary staff4 7#g7 ,relationship to ,state-imposed ratios ,nothing in this title shall preempt ,state standards that the ,secretary determines to be as stringent as ,federal requirements for a staffing plan established under this title4 ,minimum direct care registered nurse-to-patient ratios established under this subsection shall not preempt ,state requirements that the ,secretary determines are as stringent as to ,federal requirements for direct care registered nurse-to-patient ratios established under this title4 7#h7 ,exemption in emergencies ,the requirements established under this subsection shall not apply during a state of emergency if a hospital is requested or expected to provide an exceptional level of emergency or other medical services4 ,if a hospital seeks to apply the exemption under this paragraph in response to a complaint filed against the hospital for a violation of the provisions of this title1 the hospital must demonstrate that prompt and diligent efforts were made to maintain required staffing levels4 ,the ,secretary shall issue guidance to hospitals that describes situations that constitute a state of emergency for purposes of the exemption under this paragraph and shall establish necessary penalties for violations of this paragraph consistent with section #cdjf4 7c7 ,development and reevaluation of staffing plan 7#a7 ,considerations in development of plan ,in developing the staffing plan1 a hospital shall provide for direct care registered nurse-to-patient ratios above the minimum direct care registered nurse-to-patient ratios required under subsection 7b7 if appropriate based upon consideration of1 at a minimum1 the following factors3 7,a7 ,the number of patients on a particular unit on a shift-by-shift basis4 7,b7 ,the acuity level and nursing care plan of patients on a particular unit on a shift-by-shift basis4 7,c7 ,the anticipated admissions1 discharges1 and transfers of patients during each shift that impacts direct patient care4 7,d7 ,specialized experience required of direct care registered nurses on a particular unit4 7,e7 ,staffing levels and services provided by licensed vocational or practical nurses1 licensed psychiatric technicians1 certified nurse assistants1 or other ancillary staff in meeting direct patient care needs not required by a direct care registered nurse4 7,f7 ,the level of familiarity with hospital practices1 policies1 and procedures by temporary agency direct care registered nurses used during a shift4 7,g7 ,obstacles to efficiency in the delivery of patient care presented by physical layout4 7#b7 ,documentation of staffing ,a hospital shall specify the system used to document actual staffing in each unit for each shift4 7#c7 ,annual reevaluation of plan 7,a7 ,in general ,a hospital shall annually evaluate its staffing plan in each unit in relation to actual patient care requirements4 7,b7 ,update ,a hospital shall update its staffing plan to the extent appropriate based on such evaluation4 7#d7 ,transparency 7,a7 ,in general ,any staffing plan or method used to create and evaluate acuity-level and adopted by a hospital under this section shall be transparent in all respects1 including disclosure of detailed documentation of the methodology used to determine nursing staffing1 identifying each factor1 assumption1 and value used in applying such methodology4 7,b7 ,public availability ,the ,secretary shall establish procedures to provide that the documentation submitted under subsection 7d7 is available for public inspection in its entirety4 7#e7 ,registered nurse participation ,a staffing plan of a hospital-- 7,a7 shall be developed and subsequent reevaluations shall be conducted under this subsection on the basis of input from direct care registered nurses at the hospital from each unit or patient care area2 and 7,b7 where such nurses are represented through collective bargaining1 shall require bargaining with the applicable recognized or certified collective bargaining representative of such nurses4 ,nothing in this title shall be construed to permit conduct prohibited under the ,national ,labor ,relations ,act or chapter #ga of title #e1 ,united ,states ,code4 7#f7 ,staffing committees ,if a hospital maintains a staffing committee1 then the committee shall include at least one registered nurse from each hospital unit and shall be composed of at least #ej percent direct care registered nurses4 ,the staffing committee shall include meaningful representation of other direct care nonmanagement staff4 ,direct care registered nurses who serve on the committee shall be selected by other direct care registered nurses from their unit4 ,other direct care nonmanagement staff shall be selected by other direct care nonmanagement staff4 ,participation on staffing committees shall be considered a part of the employee's regularly scheduled workweek4 7d7 ,submission of plan to secretary ,a hospital shall submit to the ,secretary its staffing plan and any annual updates under subsection 7c77#c77;,b74 ,a federally operated hospital may submit its staffing plan through the department or agency operating the hospital4 #cdjb4 ,posting1 records1 and audits 7a7 ,posting requirements ,in each unit1 a hospital shall post a uniform notice in a form specified by the ,secretary in regulation that-- 7#a7 explains requirements imposed under section #cdja2 7#b7 includes actual direct care registered nurse-to-patient ratios during each shift2 7#c7 includes the actual number and titles of direct care registered nurses assigned during each shift2 and 7#d7 is visible1 conspicuous1 and accessible to staff1 patients1 and the public4 7b7 ,records 7#a7 ,maintenance of records ,each hospital shall maintain accurate records of actual direct care registered nurse-to-patient ratios in each unit for each shift for no less than #c years4 ,such records shall include-- 7,a7 the number of patients in each unit2 7,b7 the identity and duty hours of-- 7i7 each direct care registered nurse assigned to each patient in each unit in each shift2 and 7ii7 ancillary staff who are under the coordination of the direct care registered nurse2 7,c7 certification that each nurse received rest and meal breaks and the identity and duty hours of each direct care registered nurse who provided such relief2 and 7,d7 a copy of each notice posted under subsection 7a74 7#b7 ,availability of records ,each hospital shall make its records maintained under paragraph 7#a7 available to-- 7,a7 the ,secretary2 7,b7 registered nurses and their collective bargaining representatives 7if any72 and 7,c7 the public under regulations established by the ,secretary1 or in the case of a federally operated hospital1 under section #eeb of title #e1 ,united ,states ,code 7commonly known as the ,freedom of ,information ,act74 7c7 ,audits ,the ,secretary shall conduct periodic audits to ensure-- 7#a7 implementation of the staffing plan in accordance with this title2 and 7#b7 accuracy in records maintained under this section4 #cdjc4 ,minimum direct care licensed practical nurse staffing requirements 7a7 ,establishment ,a hospital's staffing plan shall comply with minimum direct care licensed practical nurse staffing requirements that the ,secretary establishes for units in hospitals4 ,such staffing requirements shall be established not later than #ah months after the date of the enactment of this title1 and shall be based on the study conducted under subsection 7b74 7b7 ,study ,not later than #a year after the date of the enactment of this title1 the ,secretary1 acting through the ,director of the ,agency for ,healthcare ,research and ,quality1 shall complete a study of licensed practical nurse staffing and its effects on patient care in hospitals4 ,the ,director may contract with a qualified entity or organization to carry out such study under this paragraph4 ,the ,director shall consult with licensed practical nurses and organizations representing licensed practical nurses regarding the design and conduct of the study4 7c7 ,application of registered nurse provisions to licensed practical nurse staffing requirements ,paragraphs 7#b71 7#d77;,a71 7#d77;,b71 7#d77;,c71 and 7#f7 of section #cdja7;b71 paragraphs 7#a71 7#b71 7#c71 and 7#d7 of section #cdja7;c71 and section #cdjb shall apply to the establishment and application of direct care licensed practical nurse staffing requirements under this section pursuant to the additional staffing requirements under subsection 7b77#c77;,g7 of section #cdja and in the same manner that they apply to the establishment and application of direct care registered nurse-to-patient ratios under sections #cdja and #cdjb4 7d7 ,effective date ,the requirements of this section shall take effect as soon as practicable1 as determined by the ,secretary1 but not later than-- 7#a7 #b years after the date of the enactment of this title2 and 7#b7 in the case of a hospital in a rural area 7as defined in section #ahhf7;d77#b77;,d7 of the ,social ,security ,act71 #d years after the date of the enactment of this title4 7e7 ,study ,not later than #a year after the date of the enactment of this title1 the ,secretary1 acting through the ,director of the ,agency for ,healthcare ,research and ,quality shall complete a study of registered and practical nurse staffing requirements in clinics and other outpatient settings1 and its effects on patient care in outpatient settings4 ,the ,director may contract with a qualified entity or organization to carry out such study under this subsection4 ,the ,director shall consult with registered nurses and licensed practice nurses working in outpatient settings1 including professional nursing associations and labor organizations representing both registered and practice nurses working in outpatient settings regarding the design and conduct of the study4 #cdjd4 ,whistleblower and patient protections 7a7 ,professional obligation and rights ,all nurses have a duty and right to act based on their professional judgment in accordance with ,state nursing laws and regulations of the ,state in which the direct nursing care is being performed and to provide care in the exclusive interests of the patients and to act as the patient's advocate4 7b7 ,acceptance of patient care assignments ,the nurse is responsible for providing competent1 safe1 therapeutic1 and effective nursing care to assigned patients4 ,before accepting a patient assignment1 a nurse shall-- 7#a7 have the necessary professional knowledge1 judgment1 skills1 and ability to provide the required care2 7#b7 determine using professional judgment in accordance with ,state nursing laws and regulations of the ,state in which the direct nursing care is being performed whether the nurse is competent to perform the nursing care required2 and 7#c7 determine whether acceptance of a patient assignment would expose the patient or nurse to risk of harm4 7c7 ,objection to or refusal of assignment ,a nurse may object to1 or refuse to participate in1 any activity1 policy1 practice1 assignment1 or task if in good faith-- 7#a7 the nurse reasonably believes it to be in violation of section #cdja or #cdjc2 or 7#b7 the nurse is not prepared by education1 training1 or experience to fulfill the assignment without compromising the safety of any patient or jeopardizing the license of the nurse4 7d7 ,retaliation for objection to or refusal of assignment barred 7#a7 ,no discharge1 discrimination1 or retaliation ,no hospital shall discharge1 retaliate1 discriminate1 or otherwise take adverse action in any manner with respect to any aspect of a nurse's employment 7as defined in section #cdjg71 including discharge1 promotion1 compensation1 or terms1 conditions1 or privileges of employment1 based on the nurse's refusal of a work assignment under subsection 7c74 7#b7 ,no filing of complaint ,no hospital shall file a complaint or a report against a nurse with a ,state professional disciplinary agency because of the nurse's refusal of a work assignment under subsection 7c74 7e7 ,cause of action ,any nurse1 collective bargaining representative1 or legal representative of any nurse who has been discharged1 discriminated against1 or retaliated against in violation of subsection 7d77#a7 or against whom a complaint or report has been filed in violation of subsection 7d77#b7 may 7without regard to whether a complaint has been filed under subsection 7f7 of this section or subsection 7b7 of section #cdjf7 bring a cause of action in a ,united ,states district court4 ,a nurse who prevails on the cause of action shall be entitled to one or more of the following3 7#a7 ,reinstatement4 7#b7 ,reimbursement of lost wages1 compensation1 and benefits4 7#c7 ,attorneys' fees4 7#d7 ,court costs4 7#e7 ,other damages4 7f7 ,complaint to secretary ,a nurse1 patient1 collective bargaining representative1 or other individual may file a complaint with the ,secretary against a hospital that violates the provisions of this title4 ,for any complaint filed1 the ,secretary shall-- 7#a7 receive and investigate the complaint2 7#b7 determine whether a violation of this title as alleged in the complaint has occurred2 and 7#c7 if such a violation has occurred1 issue an order that the complaining nurse or individual shall not suffer any discharge1 retaliation1 discrimination1 or other adverse action prohibited by subsection 7d7 or subsection 7h74 7g7 ,toll-,free telephone number 7#a7 ,in general ,the ,secretary shall provide for the establishment of a toll-free telephone hotline to provide information regarding the requirements under sections #cdja through #cdjc and to receive reports of violations of such section4 7#b7 ,notice to patients ,a hospital shall provide each patient admitted to the hospital for inpatient care with the hotline described in paragraph 7#a71 and shall give notice to each patient that such hotline may be used to report inadequate staffing or care4 7h7 ,protection for reporting 7#a7 ,prohibition on retaliation or discrimination ,a hospital shall not discriminate or retaliate in any manner against any patient1 employee1 or contract employee of the hospital1 or any other individual1 on the basis that such individual1 in good faith1 individually or in conjunction with another person or persons1 has presented a grievance or complaint1 or has initiated or cooperated in any investigation or proceeding of any governmental entity1 regulatory agency1 or private accreditation body1 made a civil claim or demand1 or filed an action relating to the care1 services1 or conditions of the hospital or of any affiliated or related facilities4 7#b7 ,good faith defined ,for purposes of this subsection1 an individual shall be deemed to be acting in good faith if the individual reasonably believes-- 7,a7 the information reported or disclosed is true2 and 7,b7 a violation of this title has occurred or may occur4 7i7 ,prohibition on interference with rights 7#a7 ,exercise of rights ,it shall be unlawful for any hospital to-- 7,a7 interfere with1 restrain1 or deny the exercise1 or attempt to exercise1 by any person of any right provided or protected under this title2 or 7,b7 coerce or intimidate any person regarding the exercise or attempt to exercise such right4 7#b7 ,opposition to unlawful policies or practices ,it shall be unlawful for any hospital to discriminate or retaliate against any person for opposing any hospital policy1 practice1 or actions which are alleged to violate1 breach1 or fail to comply with any provision of this title4 7#c7 ,prohibition on interference with protected communications ,a hospital 7or an individual representing a hospital7 shall not make1 adopt1 or enforce any rule1 regulation1 policy1 or practice which in any manner directly or indirectly prohibits1 impedes1 or discourages a direct care nurse from1 or intimidates1 coerces1 or induces a direct care nurse regarding1 engaging in free speech activities or disclosing information as provided under this title4 7#d7 ,prohibition on interference with collective action ,a hospital 7or an individual representing a hospital7 shall not in any way interfere with the rights of nurses to organize1 bargain collectively1 and engage in concerted activity under section #g of the ,national ,labor ,relations ,act 7#bi ,u4,s4,c4 #aeg74 7j7 ,notice ,a hospital shall post in an appropriate location in each unit a conspicuous notice in a form specified by the ,secretary that-- 7#a7 explains the rights of nurses1 patients1 and other individuals under this section2 7#b7 includes a statement that a nurse1 patient1 or other individual may file a complaint with the ,secretary against a hospital that violates the provisions of this title2 and 7#c7 provides instructions on how to file such a complaint4 7k7 ,effective date 7#a7 ,refusal2 retaliation2 cause of action 7,a7 ,in general ,subsections 7c7 through 7e7 shall apply to objections and refusals occurring on or after the effective date of the provision of this title to which the objection or refusal relates4 7,b7 ,exception ,subsection 7c77#b7 shall not apply to objections or refusals in any hospital before the requirements of section #cdja7;a7 or #cdjc7;a71 as applicable1 apply to that hospital4 7#b7 ,protections for reporting ,subsection 7h77#a7 shall apply to actions occurring on or after the effective date of the provision to which the violation relates1 except that such subsection shall apply to initiation1 cooperation1 or participation in an investigation or proceeding on or after the date of enactment of this title4 7#c7 ,notice ,subsection 7j7 shall take effect #ah months after the date of enactment of this title4 #cdje4 ,enforcement 7a7 ,in general ,the ,secretary shall enforce the requirements and prohibitions of this title in accordance with this section4 7b7 ,procedures for receiving and investigating complaints ,the ,secretary shall establish procedures under which-- 7#a7 any person may file a complaint alleging that a hospital has violated a requirement or a prohibition of this title2 and 7#b7 such complaints shall be investigated by the ,secretary4 7c7 ,remedies ,if the ,secretary determines that a hospital has violated a requirement of this title1 the ,secretary-- 7#a7 shall require the facility to establish a corrective action plan to prevent the recurrence of such violation2 and 7#b7 may impose civil money penalties1 as described in subsection 7d74 7d7 ,civil penalties 7#a7 ,in general ,in addition to any other penalties prescribed by law1 the ,secretary may impose civil penalties as follows3 7,a7 ,hospital liability ,the ,secretary may impose on a hospital found to be in violation of this title a civil money penalty of-- 7i7 not more than #be1jjj for the first knowing violation of this title by such hospital2 and 7ii7 not more than #ej1jjj for any subsequent knowing violation of this title by such hospital4 7,b7 ,individual liability ,the ,secretary may impose on an individual who-- 7i7 is employed by a hospital found by the ,secretary to have violated this title2 and 7ii7 knowingly violates this title1 a civil money penalty of not more than #bj1jjj for each such violation by the individual4 7#b7 ,procedures ,the provisions of section #aabh;,a of the ,social ,security ,act 7other than subsections 7a7 and 7b77 shall apply with respect to a civil money penalty or proceeding under this subsection in the same manner as such provisions apply with respect to a civil money penalty or proceeding under such section #aabh;,a4 7e7 ,public notice of violations 7#a7 ,internet website ,the ,secretary shall publish on the internet website of the ,department of ,health and ,human ,services the names of hospitals on which a civil money penalty has been imposed under this section1 the violation for which such penalty was imposed1 and such additional information as the ,secretary determines appropriate4 7#b7 ,change of ownership ,with respect to a hospital that had a change of ownership1 as determined by the ,secretary1 penalties imposed on the hospital while under previous ownership shall no longer be published by the ,secretary pursuant to paragraph 7#a7 after the #a-year period beginning on the date of change of ownership4 7f7 ,use of funds ,funds collected by the ,secretary pursuant to this section are authorized to be appropriated to carry out this title4 #cdjf4 ,definitions ,for purposes of this title3 7#a7 ,acuity level ,the term acuity level means the determination1 using a hospital acuity measurement tool that has been developed and established in coordination with direct care registered nurses and made transparent pursuant to section #cdja7;c77#d71 of nursing care requirements1 based on the assigned direct care registered nurse's professional judgment of-- 7,a7 the severity and complexity of an individual patient's illness or injury2 7,b7 the need for specialized equipment2 and 7,c7 the intensity of nursing interventions required4 7#b7 ,competence ,the term competence or competent means the satisfactory application of the duties and responsibilities of a registered nurse in providing nursing care to specific patient populations and for acuity levels for each patient care unit or area pursuant to the ,state nursing laws and regulations of the ,state in which the direct nursing care is being performed4 7#c7 ,direct care licensed practical nurse ,the term direct care licensed practical nurse means an individual who has been granted a license by at least one ,state to practice as a licensed practical nurse or a licensed vocational nurse and who provides bedside care for one or more patients4 7#d7 ,direct care registered nurse ,the term direct care registered nurse means an individual who has been granted a license by at least one ,state to practice as a registered nurse and who provides bedside care for one or more patients4 7#e7 ,employment ,the term employment includes the provision of services under a contract or other arrangement4 7#f7 ,hospital ,the term hospital has the meaning given that term in section #ahfa7;e7 of the ,social ,security ,act4 7#g7 ,nurse ,the term nurse means any direct care registered nurse or direct care licensed practice nurse 7as the case may be71 regardless of whether or not the nurse is an employee4 7#h7 ,nursing care plan ,the term nursing care plan means a plan developed by the assigned direct care registered nurse 7in accordance with nursing law in the ,state in which the nursing care is performed7 that indicates the nursing care to be given to individual patients that-- 7,a7 considers the acuity level of the patient2 7,b7 is developed in coordination with the patient1 the patient's family1 or other representatives when appropriate1 and staff of other disciplines involved in the care of the patient2 7,c7 reflects all elements of the nursing process2 and 7,d7 recommends the number and skill mix of additional licensed and unlicensed direct care staff needed to fully implement the nursing care plan4 7#i7 ,professional judgment ,the term professional judgment means1 in accordance with ,state nursing laws and regulations of the ,state in which the direct nursing care is being performed1 the direct care registered nurse's application of knowledge1 expertise1 and experience in conducting a comprehensive nursing assessment of each patient and in making independent decisions about patient care including the need for additional staff4 7#aj7 ,staffing plan ,the term staffing plan means a staffing plan required under section #cdja4 7#aa7 ,state of emergency ,the term state of emergency-- 7,a7 means a state of emergency that is an unpredictable or unavoidable occurrence at an unscheduled or unpredictable interval1 relating to health care delivery and requiring immediate medical interventions and care2 and 7,b7 does not include a state of emergency that results from a labor dispute in the health care industry or consistent understaffing4 #cdjg4 ,rule of construction ,nothing in this title shall be construed to authorize disclosure of private and confidential patient information1 if such disclosure is not authorized or required by other applicable law4 4 7b7 ,recommendations to congress ,not later than #a year after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services shall submit to ,congress a report containing recommendations for ensuring that sufficient numbers of nurses are available to meet the requirements imposed by title ,,xxxiv of the ,public ,health ,service ,act1 as added by subsection 7a74 7c7 ,report by ,,hrsa 7#a7 ,in general ,not later than #b years after the date of enactment of this ,act1 the ,administrator of the ,health ,resources and ,services ,administration1 in consultation with the ,national ,health ,care ,workforce ,commission1 shall submit to ,congress a report regarding the relationship between nurse staffing levels and nurse retention in hospitals4 7#b7 ,updated report ,not later than #e years after the date of enactment of this ,act1 the ,administrator of the ,health ,resources and ,services ,administration1 in consultation with the ,national ,health ,care ,workforce ,commission1 shall submit to ,congress an update of the report submitted under paragraph 7#a74 7d7 ,enforcement of requirements through ,federal programs 7#a7 ,medicare program ,section #ahff7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7a77#a77 is amended-- 7,a7 in subparagraph 7,x71 by striking 1 and and inserting a comma2 7,b7 in subparagraph 7,y71 by striking the period at the end and inserting 1 and2 and 7,c7 by inserting after subparagraph 7,y7 the following new subparagraph3 7,z7 in the case of a hospital1 to comply with the provisions of title ,,xxxiv of the ,public ,health ,service ,act4 4 7#b7 ,medicaid program ,section #aijb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77 is amended-- 7,a7 by striking and at the end of paragraph 7#hb72 7,b7 by striking the period at the end of paragraph 7#hc7 and inserting 2 and2 and 7,c7 by inserting after paragraph 7#hc7 the following new paragraph3 7#hd7 provide that any hospital that receives a payment under such plan comply with the provisions of title ,,xxxiv of the ,public ,health ,service ,act 7relating to minimum direct care registered nurse staffing requirements74 4 7e7 ,nursing homes ,no later than one year after enactment of this ,act1 the ,secretary of ,health and ,human ,services shall promulgate a rule for minimum staffing standards for skilled nursing facilities under the ,medicare program and for nursing facilities under the ,medicaid program that align with the standards set in this section4 #acd4 ,enhancements for reduced cost-sharing 7a7 ,in general ,section #adjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjga7 is amended-- 7#a7 in subsection 7b77#a71 by striking silver and inserting gold2 7#b7 by amending subsection 7c77#a77;,b7 to read as follows3 7,b7 ,coordination with actuarial limits ,the ,secretary shall ensure the reduction under this paragraph shall not result in the plan's share of the total allowed costs of benefits provided under the plan becoming less than-- 7i7 #ie percent in the case of an eligible insured described in paragraph 7#b77;,a72 7ii7 #ij percent in the case of an eligible insured described in paragraph 7#b77;,b72 and 7iii7 #he percent in the case of an eligible insured described in paragraph 7#b77;,c74 2 and 7#c7 by amending subsection 7c77#b7 to read as follows3 7#b7 ,additional reduction ,the ,secretary shall establish procedures under which the issuer of a qualified health plan to which this section applies shall further reduce cost-sharing under the plan in a manner sufficient to-- 7,a7 in the case of an eligible insured whose household income is not less than #ajj percent but not more than #bjj percent of the poverty line for a family of the size involved1 increase the plan's share of the total allowed costs of benefits provided under the plan to #ie percent of such costs2 7,b7 in the case of an eligible insured whose household income is more than #bjj percent but not more than #cjj percent of the poverty line for a family of the size involved1 increase the plan's share of the total allowed costs of benefits provided under the plan to #ij percent of such costs2 and 7,c7 in the case of an eligible insured whose household income is more than #cjj percent but not more than #djj percent of the poverty line for a family of the size involved1 increase the plan's share of the total allowed costs of benefits provided under the plan to #he percent of such costs4 4 7b7 ,effective date ,the amendments made by this subsection shall apply to plan years beginning after ,december #ca1 #bjai4 7c7 ,funding ,section #adjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjga7 is amended by adding at the end the following new subsection3 7g7 ,funding ,out of any funds in the ,treasury not otherwise appropriated1 there are appropriated to the ,secretary such sums as may be necessary for payments under this section4 4 #ace4 ,repeal of bonus payments for ,medicare ,advantage plans ,section #ahec7o7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7o77 is repealed4 ,,ii ,,tax ,,provisions #bja4 ,sunset of ,public ,law #aae-ig 7a7 ,in general ,all provisions of1 and amendments made by1 ,public ,law #aae-ig shall not apply to calendar1 taxable1 plan1 or limitation years beginning after ,december #ca1 #bjai4 7b7 ,application of certain laws ,the ,internal ,revenue ,code of #aihf shall be applied and administered to years described in subsection 7a7 as if the provisions and amendments described in subsection 7a7 had never been enacted4 #bjb4 ,surtax ,there is hereby imposed a tax of #e percent on the adjusted gross income of each taxpayer to the extent such income exceeds #ejj1jjj4 #bjc4 ,basis of property acquired from a decedent 7a7 ,in general ,section #ajad of the ,internal ,revenue ,code of #aihf is amended by striking person1 be and all that follows through the period at the end and inserting the following3 person1 be the basis in the hands of the decedent44 7b7 ,effective date ,the amendments made by this section to property acquired or passed after the date of enactment of this ,act4 #bjd4 ,medicare payroll tax 7a7 ,in general ,section #caja7;b77#b7 of the ,internal ,revenue ,code of #aihf is amended by striking #j4i percent and inserting #d percent4 7b7 ,effective date ,the amendments made by this section shall apply with respect to taxable years beginning after the date of the enactment of this ,act4 #bje4 ,net investment income tax 7a7 ,in general ,section #adaa7;a7 of the ,internal ,revenue ,code of #aihf is amended by striking #c4h percent each place such term appears and inserting #f4i percent4 7b7 ,effective date ,the amendments made by this section shall apply with respect to taxable years beginning after the date of the enactment of this ,act4 #bjf4 ,termination of deduction for contributions to health savings accounts ,section #bbc7;b7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new paragraph3 7#i7 ,termination of deduction ,notwithstanding any other provision of this subsection1 the monthly limitation for any month beginning after ,december #ca1 #bjbc1 is zero4 4 #bjg4 ,increase in excise tax on small cigars and cigarettes and other tobacco products 7a7 ,small cigars ,section #egja7;a77#a7 of the ,internal ,revenue ,code of #aihf is amended by striking #ej4cc and inserting #ajj4ff4 7b7 ,cigarettes ,section #egja7;b7 of such ,code is amended-- 7#a7 by striking #ej4cc in paragraph 7#a7 and inserting #ajj4ff2 and 7#b7 by striking #aje4fi in paragraph 7#b7 and inserting #baa4ch4 7c7 ,pipe tobacco ,section #egja7;f7 of the ,internal ,revenue ,code of #aihf is amended by striking #b4hcaa cents and inserting #ej4jj4 7d7 ,roll-,your-,own tobacco ,section #egja7;g7 of such ,code is amended by striking #bd4gh and inserting #di4ef4 7e7 ,large cigars ,paragraph 7#b7 of section #egja7;a7 of the ,internal ,revenue ,code of #aihf is amended by striking #eb4ge percent and all that follows through the period and inserting #bd4gh per pound 7and a proportionate tax at the like rate on all fractional parts of a pound7 but not less than #e4jcc cents per cigar44 7f7 ,smokeless tobacco 7#a7 ,in general ,section #egja7;e7 of the ,internal ,revenue ,code of #aihf is amended-- 7,a7 in paragraph 7#a71 by striking #a4ea and inserting #bh4jd2 7,b7 in paragraph 7#b71 by striking #ej4cc cents and inserting #ab4db2 and 7,c7 by adding at the end the following3 7#c7 ,smokeless tobacco sold in discrete single-use units ,on discrete single-use units1 #ajg4fe per each #a1jjj single-use units4 4 7#b7 ,discrete single-use unit ,section #egjb7m7 of such ,code is amended-- 7,a7 in paragraph 7#a71 by striking or chewing tobacco and inserting chewing tobacco1 discrete single-use unit2 7,b7 in paragraphs 7#b7 and 7#c71 by inserting that is not a discrete single-use unit before the period in each such paragraph2 and 7,c7 by adding at the end the following3 7#d7 ,discrete single-use unit ,the term discrete single-use unit means any product containing tobacco that-- 7,a7 is not intended to be smoked2 and 7,b7 is in the form of a lozenge1 tablet1 pill1 pouch1 dissolvable strip1 or other discrete single-use or single-dose unit 4 #bjh4 ,excise tax on alcohol 7a7 ,distilled spirits ,section #ejja7;a77#a7 of the ,internal ,revenue ,code of #aihf is amended by striking #ac4ej and inserting #af4jj4 7b7 ,wine 7#a7 ,section #ejda7;b77#a7 of the ,internal ,revenue ,code of #aihf is amended by striking #a4jg per wine gallon and inserting #af4jj per proof gallon4 7#b7 ,section #ejda7;b77#b7 of the ,internal ,revenue ,code of #aihf is amended by striking #a4eg per wine gallon and inserting #af4jj per proof gallon4 7#c7 ,section #ejda7;b77#c7 of the ,internal ,revenue ,code of #aihf is amended by striking #c4ae per wine gallon and inserting #af4jj per proof gallon4 7#d7 ,section #ejda7;b77#d7 of the ,internal ,revenue ,code of #aihf is amended by striking #c4dj per wine gallon and inserting #af4jj per proof gallon4 7#e7 ,section #ejda7;b77#e7 of the ,internal ,revenue ,code of #aihf is amended by striking #c4cj per wine gallon and inserting #af4jj per proof gallon4 7#f7 ,section #ejda7;b77#c7 of the ,internal ,revenue ,code of #aihf is amended by striking #bb4f cents per wine gallon and inserting #af4jj per proof gallon4 7c7 ,beer ,section #ejea7;,b7 of the ,internal ,revenue ,code of #aihf is amended by striking #ah for per barrel and inserting #af per proof gallon4 #bji4 ,tax on sugared drinks 7a7 ,in general ,subchapter ,d of chapter #cb of the ,internal ,revenue ,code of #aihf is amended by inserting after part ,i the following new part3 ,,ii ,sugar-,sweetened beverages ,sec4 #daga4 ,imposition of tax4 ,sec4 #dagb4 ,definitions4 ,sec4 #dagc4 ,special rules4 #daga4 ,imposition of tax 7a7 ,in general ,there is hereby imposed a tax on the sale or transfer of any specified sugar-sweetened beverage product by the manufacturer1 producer1 or importer thereof4 7b7 ,rate of tax ,the rate of tax imposed under subsection 7a7 shall be equal to one cent per #d4b grams of caloric sweetener contained in such specified sugar-sweetened beverage product4 7c7 ,persons liable for tax ,the manufacturer1 producer1 or importer referred to in subsection 7a7 shall be liable for the tax imposed by such subsection4 #dagb4 ,definitions 7a7 ,specified sugar-,sweetened beverage product ,for purposes of this part-- 7#a7 ,in general ,for purposes of this part1 the term specified sugar-sweetened beverage product means-- 7,a7 any liquid intended for human consumption which contains a caloric sweetener1 and 7,b7 any liquid1 or solid mixture of ingredients1 which-- 7i7 contains a caloric sweetener1 and 7ii7 is intended for use as an ingredient in a liquid described in subparagraph 7,a74 7#b7 ,exceptions ,the following shall not be treated as liquids described in paragraph 7#a77;,a73 7,a7 ,any liquid the primary ingredients of which are milk or soy1 rice1 or similar plant-based milk substitute4 7,b7 ,any liquid composed entirely of one or more of the following3 7i7 ,the original liquid resulting from the pressing of fruit or vegetables4 7ii7 ,the liquid resulting from the reconstitution of fruit or vegetable juice concentrate4 7iii7 ,the liquid resulting from the restoration of water to dehydrated fruit or vegetable juice4 7,c7 ,infant formula4 7,d7 ,any liquid products manufactured for use as-- 7i7 an oral nutritional therapy for persons who cannot absorb or metabolize dietary nutrients from food or beverages1 7ii7 a source of necessary nutrition used due to a medical condition1 or 7iii7 an oral electrolyte solution for infants and children formulated to prevent dehydration due to illness4 7,e7 ,any liquid with respect to which tax is imposed under chapter #ea 7relating to distilled spirits1 wines1 and beer7 or under section #gfeb by reason of the tax imposed under chapter #ea being imposed on like articles of domestic manufacture4 7b7 ,caloric sweetener ,for purposes of this part1 the term caloric sweetener means monosaccharides1 disaccharides1 and high-fructose corn syrup4 #dagc4 ,special rules 7a7 ,sweetener taxed only once ,in the case of any specified sugar-sweetened beverage product which is manufactured or produced by including one or more other specified sugar-sweetened beverage products1 no tax shall be imposed under this section on any caloric sweetener contained in the resulting specified sugar-sweetened beverage product if tax was previously imposed under this section on such caloric sweetener when contained in the specified sugar-sweetened beverage product so included4 7b7 ,inflation adjustment ,in the case of any sale after ,december #ca1 #bjae1 the one cent amount in section #daga7;b7 shall be increased by an amount equal to-- 7#a7 such amount1 multiplied by 7#b7 the cost-of-living adjustment determined under section #a7;f77#c7 for the calendar year in which such sale occurs1 determined by substituting calendar year #bjad for calendar year #aiib in subparagraph 7,b7 thereof4 ,any increase determined under this subsection shall be rounded to the nearest multiple of one-tenth of a cent4 4 7b7 ,conforming amendments 7#a7 ,section #dbba7;a7 is amended by adding at the end the following3 ,paragraphs 7#a71 7#d71 7#e71 and 7#f7 shall not apply to the tax imposed under section #daga44 7#b7 ,the table of parts for subchapter ,d of chapter #cb of such ,code is amended by inserting after the item relating to part ,i the following new item3 ,part ,,ii--,sugar-,sweetened beverages 4 7c7 ,effective date 7#a7 ,in general ,except as provided in paragraph 7#b71 the amendments made by this section shall take effect on the date of the enactment of this ,act4 7#b7 ,excise tax ,the amendments made by subsections 7a7 and 7b7 shall apply to sales after the date of the enactment of this ,act4 #baj4 ,repeal of excise tax on high-cost employer-sponsored health coverage 7a7 ,in general ,chapter #dc of the ,internal ,revenue ,code of #aihf is amended by striking section #dihj;,i4 7b7 ,conforming amendment ,section #fjea of such ,code is amended-- 7#a7 in paragraph 7#ad7 of subsection 7a71 by striking section #dihj;,i7d77#a7 and inserting subsection 7g71 and 7#b7 by adding at the end the following3 7g7 ,applicable employer-,sponsored coverage ,for purposes of subsection 7a77#ad7-- 7#a7 ,in general ,the term applicable employer-sponsored coverage means1 with respect to any employee1 coverage under any group health plan made available to the employee by an employer which is excludable from the employee's gross income under section #ajf1 or would be so excludable if it were employer-provided coverage 7within the meaning of such section #ajf74 7#b7 ,exceptions ,the term applicable employer-sponsored coverage shall not include-- 7,a7 any coverage 7whether through insurance or otherwise7 described in section #ihcb7;c77#a7 7other than subparagraph 7,g7 thereof7 or for long-term care2 7,b7 any coverage under a separate policy1 certificate1 or contract of insurance which provides benefits substantially all of which are for treatment of the mouth 7including any organ or structure within the mouth7 or for treatment of the eye2 or 7,c7 any coverage described in section #ihcb7;c77#c7 the payment for which is not excludable from gross income and for which a deduction under section #afb7l7 is not allowable4 7#c7 ,coverage includes employee paid portion ,coverage shall be treated as applicable employer-sponsored coverage without regard to whether the employer or employee pays for the coverage4 7#d7 ,governmental plans included ,applicable employer-sponsored coverage shall include coverage under any group health plan established and maintained primarily for its civilian employees by the ,government of the ,united ,states1 by the government of any ,state or political subdivision thereof1 or by any agency or instrumentality of any such government4 7#e7 ,cost of coverage 7,a7 ,health ,,fsas ,in the case of applicable employer-sponsored coverage consisting of coverage under a flexible spending arrangement 7as defined in section #bbje7;g771 the cost of the coverage shall be equal to the amount determined under rules similar to the rules of section #dihj;,b7f77#d7 with respect to any reimbursement under the arrangement reduced by the contributions described in subsection 7a77#ad77;,b74 7,b7 ,archer msas and hsas ,in the case of applicable employer-sponsored coverage consisting of coverage under an arrangement under which the employer makes contributions described in subsection 7b7 or 7d7 of section #ajf1 the cost of the coverage shall be equal to the amount of employer contributions under the arrangement until the termination of ,h,s,as as described under section #bjf of such ,act4 7,c7 ,allocation on a monthly basis ,if cost is determined on other than a monthly basis1 the cost shall be allocated to months in a taxable period on such basis as the ,secretary may prescribe4 4 7c7 ,clerical amendment ,the table of sections for chapter #dc of such ,code is amended by striking the item relating to section #dihj;,i4 7d7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjai4 ,,iii ,,drug-,,related ,,provisions #cja4 ,establishment of the ,prescription ,drug and ,medical ,device ,review ,board ,there is established in the ,department of ,health and ,human ,services a board to be known as the ,prescription ,drug and ,medical ,device ,price ,review ,board 7in this ,act referred to as the ,board74 #cjb4 ,membership2 staff 7a7 ,members ,the ,board shall be composed of the members as follows3 7#a7 ,the ,assistant ,secretary for ,planning and ,evaluation of the ,department of ,health and ,human ,services 7or the ,assistant ,secretary's designee74 7#b7 ,the ,administrator of the ,centers for ,medicare ,medicaid ,services or1 beginning with #bjbb1 the ,administrator of the ,center for ,health ,care 7or the ,administrator's designee74 7#c7 ,the ,assistant ,director for the ,health ,services ,division of the ,federal ,bureau of ,prisons 7or the ,assistant ,director's designee74 7#d7 ,the ,secretary of ,defense 7or the ,secretary's designee74 7#e7 ,the ,secretary of ,veterans ,affairs 7or the ,secretary's designee74 7#f7 ,the ,commissioner of ,food and ,drugs 7or the ,commissioner's designee74 7#g7 ,the ,director of the ,national ,institutes of ,health 7or the ,director's designee74 7b7 ,chairperson ,the ,board shall designate #a member of the ,board to serve as the chairperson4 7c7 ,director and staff 7#a7 ,director ,the ,board shall have a director who shall be appointed by the chairperson of the ,board1 subject to rules prescribed by the ,board4 7#b7 ,staff ,the director may appoint and fix the pay of such additional personnel as the chairperson considers appropriate1 subject to rules prescribed by the ,board4 7#c7 ,applicability of certain civil service laws ,the director and staff of the ,board shall be appointed subject to the provisions of title #e1 ,united ,states ,code1 governing appointments in the competitive service1 and shall be paid in accordance with the requirements of chapter #ea and subchapter ,,iii of chapter #ec of such title relating to classification and ,general ,schedule pay rates2 except that an individual so appointed may not receive pay in excess of the maximum annual rate of basic pay payable for grade ,,gs-#ae of the ,general ,schedule4 7d7 ,assistance for the board ,subject to section #cjf7;g71 in carrying out this title1 the ,board-- 7#a7 may seek assistance from outside experts in the fields of consumer advocacy1 medicine1 pharmacology1 pharmacy1 and prescription drug reimbursement2 and 7#b7 shall establish and maintain an advisory group and a stakeholder group for purposes of seeking such assistance4 7e7 ,initial meeting ,the ,board shall hold its initial meeting not later than #ij days after the date of the enactment of this ,act4 7f7 ,banned individuals 7#a7 ,drug company lobbyists ,no former registered drug manufacturer lobbyist-- 7,a7 may be appointed to the position of ,director of the ,office2 or 7,b7 may be employed by the ,office during the #f-year period beginning on the date on which the registered lobbyist terminates its registration in accordance with section #d7;d7 of the ,lobbying ,disclosure ,act of #aiie 7#b ,u4,s4,c4 #afjc7;d77 or the agent terminates its status1 as applicable4 7#b7 ,senior executives of law-breaking companies ,no former senior executive of a covered entity-- 7,a7 may be appointed to the position of ,director of the ,office2 or 7,b7 may be employed by the ,office during the #f-year period beginning on the later of-- 7i7 the date of the settlement2 and 7ii7 the date on which the enforcement action has concluded4 7#c7 ,covered entity ,the term covered entity means any entity that is-- 7,a7 a drug manufacturer2 and 7,b7 7i7 operating under ,federal settlement1 including a ,federal consent decree2 or 7ii7 the subject of an enforcement action in a court of the ,united ,states or by an agency4 #cjc4 ,prohibition against excessive price 7a7 ,prohibition ,beginning on the effective date of the regulation required by subsection 7b71 the manufacturer of a prescription drug or medical device shall not charge an excessive price1 as determined pursuant to such regulation1 for such drug or device4 7b7 ,formula ,the ,board shall by regulation prescribe a formula for determining whether the average manufacturer price of such drug or device over an annual quarter is an excessive price4 7c7 ,determination of excessive price ,if the ,board determines1 on its own initiative or in response to a petition submitted under subsection 7d71 that the manufacturer of a prescription drug or medical device charges an excessive price for such drug or device in violation of subsection 7a7-- 7#a7 the ,board shall give the manufacturer-- 7,a7 notice of such violation2 and 7,b7 subject to subsection 7d71 a period to correct such violation2 and 7#b7 if the manufacturer fails to correct the violation by the end of such period1 the manufacturer shall be subject to section #cjd1 section #aibg7;c77#b77;,e7 of the ,social ,security ,act 7as added by subsection 7c7 of section #cjd71 and section #daib of the ,internal ,revenue ,code of #aihf1 as added by subsection 7d7 of section #cjd4 7d7 ,petitions ,any person may petition the ,board to make a determination under subsection 7c7 regarding the pricing of a prescription drug or medical device4 ,not later than #ij days after the date of receipt of such a petition1 the ,board shall-- 7#a7 make a determination under subsection 7c7 regarding such pricing2 or 7#b7 decline to make such a determination4 7e7 ,continuing violation ,the ,board shall not be required to give a manufacturer an opportunity to correct a violation1 as described in subsection 7c77#a77;,b71 before the manufacturer becomes subject to the provisions described in subsection 7c77#b7 for such violation1 if-- 7#a7 the ,board has already provided such an opportunity to correct to the manufacturer2 and 7#b7 the ,board finds that the violation of subsection 7a7 is a continuation of an earlier violation with respect to which such an opportunity was provided4 7f7 ,considerations ,the formula required by subsection 7a7 shall at a minimum take into consideration-- 7#a7 the average manufacturer price of the prescription drug or medical device over the respective annual quarter or quarters2 7#b7 the average manufacturer price of other prescription drugs or medical devices in the same therapeutic class over the same quarter or quarters2 7#c7 the average price at which the prescription drug or medical device and other prescription drugs and medical devices in the same therapeutic class have been sold by manufacturers in countries other than the ,united ,states2 7#d7 the costs associated with producing and marketing the prescription drug or medical device1 the value of the drug or device to patients where sufficient data is available to determine such value1 the total ,federal investment in the development of the drug or device1 the size of the patient population receiving the drug or device1 and other factors determinative as to the true cost of production2 and 7#e7 whether the price of the prescription drug or medical device increased during any annual quarter by a percentage that is more than #b percent greater than the ,,cpi increase percentage 7as defined in section #bae7;i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #dae77 for the respective annual quarter4 7g7 ,value or cost-,effectiveness assessments ,the use of ,quality-,adjusted ,life ,years1 ,disability-,adjusted ,life ,years1 or other similar mechanisms is prohibited for use in value or cost-effectiveness assessments for purposes of this section4 #cjd4 ,enforcement provisions 7a7 ,reduced patent term ,if the ,board finds that the manufacturer of a prescription drug or medical device1 who is also an owner of a patent for such drug or device1 charged an excessive price for such drug or device in violation of section #cjc7;a71 the ,board may-- 7#a7 reduce the term1 by not more than #e years1 of any patent issued under title #ce1 ,united ,states ,code1 relating to such drug or device2 or 7#b7 if the term of each patent for such drug or device has expired1 reduce the term1 by not more than #e years1 of another patent owned by the patent owner relating to a prescription drug or medical device4 7b7 ,civil penalties ,if the ,board determines under section #cjc7;c7 that a manufacturer of a prescription drug or medical device charged an excessive price for a prescription drug or medical device in violation of section #cjc7;a71 the ,board may impose a civil penalty on the manufacturer of not more than #aj percent of the manufacturer's gross sales of the drug or device during the period beginning on the date on which an excessive price is first charged and ending on the date on which the manufacturer ceases to charge an excessive price4 7c7 ,tax on excess prescription drug and medical device profits 7#a7 ,determination of amount ,if the ,board determines under section #cjc7;a7 that a manufacturer1 producer1 or importer of a prescription drug or medical device charged an excessive price for such prescription drug or medical device during a taxable year1 the ,board may determine under this paragraph a reasonable price for such drug or device for such taxable year4 7#b7 ,imposition of tax 7,a7 ,in general ,the ,internal ,revenue ,code of #aihf is amended by inserting after section #daia the following new section3 #daib4 ,excessive prescription drug and medical device price 7a7 ,in general ,there is hereby imposed on the sale of any prescription drug or medical device by the manufacturer1 producer1 or importer a tax equal to the difference between the price at which such drug or device is so sold and the reasonable price determined by the ,prescription ,drug and ,medical ,device ,price ,review ,board under section #cjc7;c77#a7 of the ,medicare for ,america ,act for such drug or device for the taxable year for sales after the determination4 7b7 ,prescription drug or medical device ,for purposes of this section1 the term prescription drug or medical device means any prescription drug 7as defined in section #ijjh of the ,patient ,protection and ,affordable ,care ,act7 or device 7as defined in section #bja7;h7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act7 intended for humans4 4 7,b7 ,clerical amendment ,the table of parts for chapter #cb of such ,code is amended-- 7i7 in the item relating to subchapter ,e1 by striking ,medical and inserting ,drugs and medical2 and 7ii7 by inserting after the item relating to section #daia the following new item3 ,sec4 #daib4 ,excessive prescription drug and medical device price4 4 7#c7 ,effective date ,this subsection and the amendments made by this subsection shall apply with respect to sales after ,december #ca1 #bjai4 #cje4 ,authority 7a7 ,obtaining official data ,the chairperson of the ,board may secure directly from any ,federal agency information necessary to enable the ,board to carry out its duties4 ,upon request of the chairperson1 the head of the agency shall furnish such information to the ,board to the extent such information is not prohibited from disclosure by law4 7b7 ,mails ,the ,board may use the ,united ,states mails in the same manner and under the same conditions as other ,federal agencies4 7c7 ,administrative support services ,upon the request of the chairperson of the ,board1 the ,administrator of ,general ,services shall provide to the ,board1 on a reimbursable basis1 the administrative support services necessary for the ,board to carry out its duties4 7d7 ,contract authority ,the ,board may contract with and compensate government and private agencies or persons for the purpose of conducting research1 surveys1 and other services necessary to enable the ,board to carry out its duties4 7e7 ,investigations ,the ,board may make such investigations as it considers necessary to determine whether there is or may be a violation of any regulation promulgated under this ,act and may require or permit any person to file with it a statement in writing1 under oath or otherwise as the ,board shall determine1 as to all the facts and circumstances concerning the matter to be investigated4 7f7 ,subpoena power 7#a7 ,in general ,the ,board may issue subpoenas requiring the attendance and testimony of witnesses and the production of any evidence relating to any matter under investigation by the ,board4 ,the attendance of witnesses and the production of evidence may be required from any place within the ,united ,states at any designated place of hearing within the ,united ,states4 7#b7 ,failure to obey a subpoena ,if a person refuses to obey a subpoena issued under paragraph 7#a71 the ,board may apply to a ,united ,states district court for an order requiring that person to appear before the ,board to give testimony1 produce evidence1 or both1 relating to the matter under investigation4 ,the application may be made within the judicial district where the hearing is conducted or where that person is found1 resides1 or transacts business4 ,any failure to obey the order of the court may be punished by the court as civil contempt4 7#c7 ,service of subpoenas ,the subpoenas of the ,board shall be served in the manner provided for subpoenas issued by a ,united ,states district court under the ,federal ,rules of ,civil ,procedure for the ,united ,states district courts4 7#d7 ,service of process ,all process of any court to which application is made under paragraph 7#b7 may be served in the judicial district in which the person required to be served resides or may be found4 7#e7 ,notice ,upon issuing any subpoena under this subsection1 the ,board shall give notice of such issuance to the appropriate committees of ,congress1 including the ,committee on ,appropriations of the ,house of ,representatives and the ,committee on ,appropriations of the ,senate4 7g7 ,confidentiality ,under this title1 the ,secretary shall enforce applicable law concerning a trade secret or confidential information subject to section #eeb7;b77#d7 of title #e1 ,united ,states ,code1 or section #aije of title #ah4 #cjf4 ,regulations 7a7 ,in general ,not later than #a year after the date of the initial meeting held under section #cjb7;e71 the ,board shall issue final regulations to carry out this ,act4 7b7 ,notice and comment requirement ,the regulations developed under subsection 7a7 shall be issued in accordance with the notice and comment procedures established under section #eec of title #e1 ,united ,states ,code4 #cjg4 ,report to ,federal agencies ,not later than #a year after the effective date of the regulations under section #cjf and annually thereafter1 the ,board shall submit to each ,federal agency that dispenses or makes payments for the dispensing of prescription drugs or medical devices a report containing a list of each prescription drug and medical device for which an excessive price was charged during the preceding calendar year1 as determined by the ,board under section #cjc4 ,the ,secretary shall make this report publicly available4 #cjh4 ,definitions ,in this title3 7#a7 ,affiliate ,the term affiliate means1 with respect to a manufacturer1 any entity that controls1 is controlled by1 or is under common control with such manufacturer4 7#b7 ,average manufacturer price ,the term average manufacturer price means the average price charged by the manufacturer of a prescription drug or medical device1 as applicable1 for sales of the drug or device by the manufacturer in the ,united ,states over the respective annual quarter4 7#c7 ,medical device ,the term medical device means a device 7as defined in section #bja of the ,federal ,food1 ,drug1 and ,cosmetic ,act 7#ba ,u4,s4,c4 #cba774 7#d7 ,prescription drug ,the term prescription drug means a drug 7as defined in section #bja of the ,federal ,food1 ,drug1 and ,cosmetic ,act 7#ba ,u4,s4,c4 #cba77 that is subject to section #ejc7;b77#a7 of such ,act 7#ba ,u4,s4,c4 #cec7;b77#a774 7#e7 ,manufacturer ,the term manufacturer means the person-- 7,a7 that holds the application for a drug approved under section #eje of the ,federal ,food1 ,drug1 and ,cosmetic ,act or the license issued under section #cea of the ,public ,health ,service ,act2 or 7,b7 who is responsible for setting the price for the drug4 7#f7 ,wholesale acquisition cost ,the term wholesale acquisition cost has the meaning given that term in section #ahdg;,a7c77#f77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c;a7c77#f77;,b774 #cji4 ,moratorium on direct-to-consumer drug advertising ,the ,federal ,food1 ,drug1 and ,cosmetic ,act 7#ba ,u4,s4,c4 #cja et seq47 is amended-- 7#a7 in section #cja 7#ba ,u4,s4,c4 #cca71 by adding at the end the following3 7eee7 ,the conduct of direct-to-consumer advertising of a drug in violation of section #ejf;,j4 2 and 7#b7 in chapter ,v1 by inserting after section #ejf;,i 7#ba ,u4,s4,c4 #cef;f7 the following3 #ejf;,j4 ,direct-to-consumer drug advertising 7a7 ,prohibitions 7#a7 ,first three years 7,a7 ,in general ,subject to subparagraph 7,b71 no person shall conduct direct-to-consumer advertising of a drug for which an application is submitted under section #eje7;b7 before the end of the #c-year period beginning on the date of the approval of such application4 7,b7 ,waiver ,the ,secretary may waive the application of subparagraph 7,a7 to a drug during the third year of the #c-year period described in such subparagraph if-- 7i7 the sponsor of the drug submits an application to the ,secretary pursuant to subparagraph 7,c72 and 7ii7 the ,secretary1 after considering the application and any accompanying materials1 determines that direct-to-consumer advertising of the drug would have an affirmative value to public health4 7,c7 ,application for waiver ,to seek a waiver under subparagraph 7,b71 the sponsor of a drug shall submit an application to the ,secretary at such time1 in such manner1 and containing such information as the ,secretary may require4 7#b7 ,subsequent years ,the ,secretary may prohibit direct-to-consumer advertising of a drug during the period beginning at the end of the #c-year period described in paragraph 7#a77;,a7 if the ,secretary determines that the drug has significant adverse health effects based on post-approval studies1 risk-benefit analyses1 adverse event reports1 the scientific literature1 any clinical or observational studies1 or any other appropriate resource4 7b7 ,regulations ,not later than #a year after the date of the enactment of this section1 the ,secretary shall revise the regulations promulgated under this ,act governing drug advertisements to the extent necessary to implement this section4 7c7 ,rule of construction ,this section shall not be construed to diminish the authority of the ,secretary to prohibit or regulate direct-to-consumer advertising of drugs under other provisions of law4 4 #caj4 ,reporting on justification for drug price increases ,title ,,iii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bda et seq47 is amended by adding at the end the following3 ,w ,drug ,price ,reporting2 ,drug ,value ,fund #cii,,oo4 ,reporting on justification for drug price increases 7a7 ,definitions ,in this section3 7#a7 ,manufacturer ,the term manufacturer means the person-- 7,a7 that holds the application for a drug approved under section #eje of the ,federal ,food1 ,drug1 and ,cosmetic ,act or the license issued under section #cea of the ,public ,health ,service ,act2 or 7,b7 who is responsible for setting the price for the drug4 7#b7 ,qualifying drug ,the term qualifying drug means any drug that is approved under subsection 7c7 or 7j7 of section #eje of the ,federal ,food1 ,drug1 and ,cosmetic ,act or licensed under subsection 7a7 or 7k7 of section #cea of this ,act-- 7,a7 that has a wholesale acquisition cost of #ajj or more per month supply or per a course of treatment that lasts less than a month and is-- 7i7 7,i7 subject to section #ejc7;b77#a7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act2 or 7,,ii7 commonly administered by hospitals 7as determined by the ,secretary72 7ii7 not designated as a drug for a rare disease or condition under section #ebf of the ,federal ,food1 ,drug1 and ,cosmetic ,act2 and 7iii7 not designated by the ,secretary as a vaccine2 and 7,b7 for which1 during the previous calendar year1 at least #a dollar of the total amount of sales were for individuals enrolled under the ,medicare program under title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 or under a ,state ,medicaid plan under title ,,xix of such ,act 7#db ,u4,s4,c4 #acif et seq47 or under a waiver of such plan4 7#c7 ,wholesale acquisition cost ,the term wholesale acquisition cost has the meaning given that term in section #ahdg;,a7c77#f77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c;a7c77#f77;,b774 7b7 ,report 7#a7 ,report required ,the manufacturer of a qualifying drug shall submit a report to the ,secretary for each price increase of a qualifying drug that will result in an increase in the wholesale acquisition cost of that drug that is equal to-- 7,a7 #aj percent or more over a #ab-month period2 or 7,b7 #be percent or more over a #cf-month period4 7#b7 ,report deadline ,each report described in paragraph 7#a7 shall be submitted to the ,secretary not later than #cj days prior to the planned effective date of such price increase4 7c7 ,contents ,a report under subsection 7b7 shall1 at a minimum1 include-- 7#a7 with respect to the qualifying drug-- 7,a7 the percentage by which the manufacturer will raise the wholesale acquisition cost of the drug on the planned effective date of such price increase2 7,b7 a justification for1 and description of1 each manufacturer's price increase that will occur during the #ab-month period described in subsection 7b77#a77;,a7 or the #cf-month period described in subsection 7b77#a77;,b71 as applicable2 7,c7 the identity of the initial developer of the drug2 7,d7 a description of the history of the manufacturer's price increases for the drug since the approval of the application for the drug under section #eje of the ,federal ,food1 ,drug1 and ,cosmetic ,act or the issuance of the license for the drug under section #cea1 or since the manufacturer acquired such approved application or license2 7,e7 the current list price of the drug2 7,f7 the total expenditures of the manufacturer on-- 7i7 materials and manufacturing for such drug2 and 7ii7 acquiring patents and licensing for such drug2 7,g7 the percentage of total expenditures of the manufacturer on research and development for such drug that was derived from ,federal funds2 7,h7 the total expenditures of the manufacturer on research and development for such drug that is used for-- 7i7 basic and preclinical research2 7ii7 clinical research2 7iii7 new drug development2 7iv7 pursuing new or expanded indications for such drug through supplemental applications under section #eje of the ,federal ,food1 ,drug1 and ,cosmetic ,act or section #cea of the ,public ,health ,service ,act2 and 7v7 carrying out postmarket requirements related to such drug1 including those under section #eje7o77#c7 of the ,federal ,food1 ,drug1 and ,cosmetic ,act2 7,i7 the total revenue and the net profit generated from the qualifying drug for each calendar year since the approval of the application for the drug under section #eje of the ,federal ,food1 ,drug1 and ,cosmetic ,act or the issuance of the license for the drug under section #cea1 or since the manufacturer acquired such approved application or license2 and 7,j7 the total costs associated with marketing and advertising for the qualifying drug2 7#b7 with respect to the manufacturer-- 7,a7 the total revenue and the net profit of the manufacturer for each of the #ab- and #cf-month periods preceding the submission of the report2 7,b7 all stock-based performance metrics used by the manufacturer to determine executive compensation for each of the #ab- and #cf-month periods preceding the submission of the report2 and 7,c7 any additional information the manufacturer chooses to provide related to drug pricing decisions1 such as total expenditures on-- 7i7 drug research and development2 or 7ii7 clinical trials on drugs that failed to receive approval by the ,food and ,drug ,administration2 and 7#c7 such other related information as the ,secretary considers appropriate4 7d7 ,civil penalty ,any manufacturer of a qualifying drug that fails to submit a report for the drug as required by this section shall be subject to a civil penalty of #ajj1jjj for each day on which the violation continues4 7e7 ,public posting 7#a7 ,in general ,subject to paragraph 7#c71 not later than #cj days after the submission of a report under subsection 7b71 the ,secretary shall post the report on the public website of the ,department of ,health and ,human ,services4 7#b7 ,format ,in developing the format of such report for public posting1 the ,secretary shall consult stakeholders1 including beneficiary groups1 and shall seek feedback on the content and format from consumer advocates and readability experts to ensure such public reports are user-friendly to the public and are written in plain language that consumers can readily understand4 7#c7 ,trade secrets and confidential information ,in carrying out this section1 the ,secretary shall enforce applicable law concerning the protection of confidential commercial information and trade secrets4 #cii,,oo-#a4 ,use of civil penalty amounts ,the ,secretary shall1 without further appropriation1 collect civil penalties under section #cii,,oo and use the funds derived from such civil penalties1 in addition to any other amounts available to the ,secretary1 to carry out activities described in this part and to improve consumer and provider information about drug value and drug price transparency4 #cii,,oo-#b4 ,annual report to ,congress 7a7 ,in ,general ,subject to subsection 7b71 the ,secretary shall submit to ,congress1 and post on the public website of the ,department of ,health and ,human ,services in a way that is easy to use and understand1 an annual report-- 7#a7 summarizing the information reported pursuant to section #cii,,oo2 and 7#b7 including copies of the reports and supporting detailed economic analyses submitted pursuant to such section4 7b7 ,trade secrets and confidential information ,in carrying out this section1 the ,secretary shall enforce applicable law concerning the protection of confidential commercial information and trade secrets4 4 ,,iv ,outcomes and ,reporting #dja4 ,sense of ,congress ,it is the sense of ,congress that ,medicare for ,america will have a significant impact on the health and well-being of the ,united ,states population and the social determinants of the health of beneficiaries of ,medicare for ,america4 #djb4 ,evaluation of bill's outcome 7a7 ,in general ,to assess the impact of this ,act on the health of the population1 not later than #b years after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services shall allow for analysis of administrative records that have removed all personally identifiable information from the ,center for ,health ,care to existing population surveys conducted by the ,federal ,government and federally supported surveys4 7b7 ,,cdc and ,,nih ,the ,directors of the ,centers for ,disease ,control and ,prevention and the ,national ,institutes of ,health shall solicit a comprehensive1 longitudinal study to evaluate any differential individual impact on coverage expansion based on-- 7#a7 race and ethnicity2 7#b7 socioeconomic status2 or 7#c7 health status4 7c7 ,report ,ten years after the date of the enactment of this ,act and every ten years thereafter1 the ,secretary shall submit a report to the ,house ,committee on ,energy and ,commerce and the ,senate ,committee on ,health1 ,education1 ,labor1 and ,pensions regarding impact of this ,act on the health of the ,united ,states population based on the results of subsection 7b7 contributions from all other relevant agencies4